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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicaldiagnosis1900daco 


Medical  Diagnosis 


WITH 


SPECIAL   REFERENCE   TO 
PRACTICAL    MEDICINE 


A   GUIDE  TG   THE    KNOWLEDGE    AND    DISCRIMINATION 

OF  DISEASES 


BY 

J.  M.  DA  COSTA,  M.D.,  LL.D. 

PHYSICIAN  TO   THE   PENNSYLVANIA  HOSPITAL,    ETC. 


ILLUSTRATED 


NINTH  EDITION,  REVISED 


PHILADELPHIA   AND   LONDON 

J.  B.  LIPPINCOTT   COMPANY 

1900 


Copyright,  1890,  by  J.  M.  Da  Costa,  M.D. 


Copyright,  1895,  by  J.  M.  Da  Costa,  M.D. 


Copyright,  1900,  by  J.  M.  Da  Costa,  M.D. 


PRINTED    BY    J.    B,   LIPPINCOTT    COMPANY,   PHILADELPHIA,    U.S.A. 


PREFACE   TO   THE   NINTH   EDITION. 


Considerable  new  matter  has  been  incorporated  in  this  edition, 
especially  in  the  chapters  on  the  Diseases  of  the  Stomach,  on  the 
Blood,  and  on  Fevers,  as  well  as  whatever  of  bacteriological  interest 
has  proved  of  value  for  diagnostic  purposes.  Fresh  illustrations,  too, 
including  some  skiagraphs  and  colored  plates,  have  been  added.  By 
a  revision  of  the  text,  and  the  rewriting  of  such  portions  as  now, 
with  our  more  definite  knowledge,  admit  of  greater  precision  of  ex- 
pression, the  additions  have  not  enlarged  the  book ;  indeed,  the  differ- 
ent size  of  the  page  and  a  new  type  have  made  it  a  smaller  and  more 
convenient  volume.  All  the  fresh  matter  has  been  added  in  accord- 
ance with  the  clinical  classification  inaugurated  when  the  work  was 
originally  written,  and  which  has  proved  a  useful,  plan.  I  express 
with  pleasure  my  indebtedness  to  Dr.  Eshner,  Dr.  Woodbury,  and  Dr. 
Leffmann  for  valuable  aid,  as  well  as  to  Dr.  Leonard  for  the  excellent 
skiagraphic  pictures.  The  delay  in  issuing  this  edition  has  been  caused 
by  the  great  fire  that  destroyed  the  building  of  the  publishing  com- 
pany and,  with  it,  all  the  copies  of  the  just  printed  volume.  The 
work  is  now  before  the  profession  in  the  English,  German,  Italian, 
and  Russian  languages. 

1700  Walnut  Street, 
June,  1900. 


EXTRACT    FROM    PREFACE   TO   THE   FIRST 
EDITION. 


My  chief  aim  in  writing  this  work  has  been  to  furnish  advanced 
students  and  young  graduates  of  medicine  with  a  guide  that  might  be 
of  service  to  them  in  their  endeavors  to  discriminate  disease.  I  have 
sought  to  offer  to  those  members  of  the  profession  who  are  about  to 
enter  on  its  practical  duties  a  book  on  Diagnosis  of  an  essentially 
practical  character, — one  neither  so  meagre  in  detail  as  to  be  next  to 
useless  when  they  encounter  the  manifold  and  varying  features  of  dis- 
ease, nor  so  overladen  with  unnecessary  detail  as  to  be  unwieldy  and 
lacking  in  precise  and  readily  applicable  knowledge. 

In  executing  my  undertaking,  two  plans  offered  themselves  :  either 
to  describe  morbid  states  in  compliance  with  the  usual  pathological 
classification  followed  in  treatises  on  the  Practice  of  Medicine,  or  to 
group  them  according  to  their  marked  symptoms.  The  former  plan 
would  have  been  far  the  easier,  but  the  latter  seemed  to  me  the  more 
suitable  for  a  volume  of  this  kind  ;  and,  although  it  has  involved  much 
labor,  and  has  rendered  the  task  much  more  difficult  of  accomplish- 
ment, its  advantages  appeared  to  me  so  great  that  I  have  adopted  it 
throughout.  That  this  attempt  at  a  purely  clinical  classification  is  not 
perfect,  I  am  fully  aware.  But,  with  all  its  shortcomings,  I  venture  to 
hope  that  it  will  not  be  devoid  of  value. 

Some  of  the  statements  made  may  appear  too  absolute,  and  as  not 
taking  sufficient  notice  of  the  many  exceptions  that  may  arise.  But  it 
was  impossible  to  avoid  this  without  lengthy  discussion  :  and  even  in 


4  PREFACE  TO  THE  FIRST  EDITION. 

the  lengthiest  discussion  all  exceptions  and  all  possible  points  of  fallacy 
would  not  have  been  mentioned ;  for  Nature  does  not  limit  herself  in 
her  irregularities  any  more  than  in  her  rules.  The  text  must,  there- 
fore, be  looked  upon  as  treating  only  of  general  laws  and  of  their  most 
notable  infractions  ;  in  fact,  but  as  a  series  of  etchings,  with  here  and 
there  a  prominent  figure  shaded,  but  not  as  an  attempt  to  reproduce 
the  colors  of  an  original  whose  varied  hues  could  not  be  closely  copied, 
even  by  the  hand  of  a  master.  Occasionally  the  record  of*cases  has 
been  introduced  by  way  of  elucidation.  To  have  done  this  to  a  much 
greater  extent,  though  in  some  respects  desirable,  would  have  swelled 
the  work  to  an  inordinate  size. 

The  wood-cuts  employed  as  illustrations  are  all  original.  Many 
are  from  sketches,  or  at  least  are  based  on  sketches,  taken  directly 
from  cases  of  interest. 

Philadelphia,  April,  1864. 


CONTENTS. 


INTEODUCTION. 

PAGE 

General  Considerations 17 


CHAPTBE   I. 

EXAMINATION    OP    PATIENTS,  AND    SOME    SYMPTOMS    OP    GENERAL    IMPORT. 

General  Considerations 25 

Position  of  the  Body 27 

General  Aspect — Expression  of  Countenance 29 

Skin 31 

Pulse  31 

Temperature  of  the  Body 38 

Tongue 45 

Sensations  of  Patients 48 

CHAPTEE   II. 

DISEASES   OP   THE    BRAIN   AND   SPINAL    CORD,  AND   OF   THEIR    NERVES, 

General  Considerations 50 

Cerebral  Localization 50 

Sensory  Centres,  and  Conducting  Paths 55 

Spinal  Localization - 56 

General  Symptoms 58 

Deranged  Intellection 59 

Delirium 60 

Derangement  of  Consciousness 62 

Insomnia 63 

Deranged  Sensation 64 

Hyperaesthesia 64 

Anaesthesia 65 

Paraesthesia 70 

Headache 71 

Vertigo ., 73 

Derangement  of  Special  Senses 76 

Vision  76 

Hearing 85 

Deranged  Reflexes 86 

Deranged  Motion 90 

Paralysis 90 

Hemiplegia 98 

5 


6  CONTENTS. 

PAGE 

Monoplegia 104 

Paraplegia 106 

Sudden  Paraplegia 107 

Spinal  Hemorrhage 107 

Acute  Ascending  Paralysis 108 

Multiple  Xeuritis 109 

Infectious  Paralyses 112 

Gradual  Paraplegia 112 

Spinal  Congestion 112 

Spinal  Anaemia 113 

Spinal  Meningitis 113 

Myelitis 114 

Spinal  Scleroses 116 

Tumors  of  the  Cord 117 

Reflex  Paraplegia 118 

Palsies  usually  Limited,  though  they  may  be  General 118 

Hysterical  Paralysis 118 

Rheumatic  Paralysis 120 

Lead  Palsy 121 

Diphtheritic  Paralysis 121 

Syphilitic  Paralysis 122 

Local  Palsies 124 

Facial  Palsy 124 

Paralysis  of  the  Xerves  of  the  Arm 126 

Bulbar  Paralysis 127 

Palsies  connected  ^^dth  Marked  Muscular  Wasting 128 

Progressive  ^luscular  Atrophy 128 

Infantile  Paralysis 133 

Ataxia 138 

Locomotor  Ataxia 138 

Diseases  of  the  Cerebellum .- 143 

Tremor 144 

Paralysis  Agitans 144 

^Multiple  Cerebro-spinal  Sclerosis 145 

Functional  Tremors 147 

Spasms — Con^Tllsions 149 

Deranged  Nutrition  and  Secretion 151 

Acute  Affections  of  which  Delirium  is  a  Prominent  SjTnptom 155 

Acute  i\Ieningitis 155 

Tubercular  ^Meningitis 160 

Cerebro-spinal  ^Meningitis 163 

Delirium  Tremens 164 

Acute  Mania 166 

Disease  marked  by  Sudden  Loss  of  Consciousness  and  of  ^'oluntary  Motion. .  167 

Apoplexy 167 

Aphasia  . .  .• 177 

Sun-stroke , 180 

Catalepsy 182 

Diseases  marked  by  Convulsions  or  Spasms 184 

Epilepsy 184 

Chorea 188 


CONTENTS.  7 

PAGE 

Hysteria 193 

Tetanus 197 

Functional  Spasms 202 

Hiccough 203 

Diseases  of  Ill-Regulated  or  Deficient  Nerve-Force 204 

Neurasthenia 204 

Diseases  characterized  by  Gradual  Impairment  of  the  Mental  Faculties  with 

Paralysis 207 

Chronic  Softening 207 

Tumor 210 

General  Paralysis 215 

Diseases  characterized  by  Enlargement  of  the  Head 217 

Chronic  Hydrocephalus 217 

Hypertrophy  of  the  Brain 218 

Diseases  characterized  by  Enlargement  of  Various  Parts 219 

Acromegalia 219 

Diseases  characterized  by  Paroxysmal  Pain  . . .  ■. 220 

Neuralgia  in  General 220 

Facial  Neuralgia 221 

Hemicrania 223 

Sciatica 224 

General  Crural  Neuritis 226 

Brachial  Neuritis 226 


CHAPTEE  III. 

DISEASES    OF   THE   UPPER   AIR-PASSAGES.  , 

SECTION    I. 
DISEASES  OF  THE  NOSE  AND   ASSOCIATE  ORGANS. 

General  Considerations 228 

SECTION  II. 

DISEASES   OF  THE  LARYNX   AND  TRACHEA. 

General  Considerations '. .  233 

Acute  Laryngeal  Affections 240 

Acute  Laryngitis 240 

Oedema  of  the  Larynx 242 

Croup 243 

Chronic  Laryngeal  Affections 249 

Chronic  Laryngitis .- 249 

CHAPTEE  IV. 

DISEASES    OF   THE    CHEST. 

General  Considerations 259 


8  CONTENTS. 

SECTIOX  I. 

DISEASES   OF  THE    LUNGS. 

PAGE 

Different  Methods  of  Physical  Diagnosis,  and  the  Physical  Signs  of  Pul- 
monary Diseases 260 

Inspection 260 

Mensuration 264 

Palpation 265 

Percussion 266 

Percussion  of  the  Healthy  Chest 270 

Auscultation 271 

Sounds  of  Eespiration  in  Health  and  in  Disease 274 

Changes  in  the  Vesicular  ]Murmur 275 

Bronchial  Respiration 278 

Xew  or  Adventitious  Sounds 280 

Ausciiltation  of  the  Voice 284 

Combination  of  the  Physical  Signs,  and  the  Examination  of  Patients  affected 

with  Disease  of  the  Lungs 285 

Principal  Symptoms  of  Diseases  of  the  Lungs 287 

Dyspnoea 287 

Cough 291 

The  Sputum 294 

Heemoptysis 299 

Diseases  in  T\-hich  Clearness  on  Percussion  is  met  with 302 

Acute  Bronchitis 302 

Chronic  Bronchitis 306 

Emphysema 309 

Diseases  in  which  Dulness  on  Percussion  occurs 313 

Phthisis' 313 

Acute  Affections  of  the  Lungs  accompanied  by  Dulness  on  Percussion 331 

Acute  Tuberculosis 331 

Acute  Pneumonia 334 

Acute  Pleurisy 348 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of  the  Liver  or 

Heart,  and  Dyspnoea 352 

Pneumothorax 353 

Chronic  Pleurisy 357 

Diseases  in  which  Eetraction  of  the  Chest  occurs 363 

Chronic  Pleurisy 363 

SECTION   II. 

DISEASES   OF  THE  HEART. 

General  Considerations 367 

Examination  of  the  Heart  by  the  Different  ^Methods  of  Physical  Diagnosis 369 

Inspection 370 

Palpation 370 

Percussion 371 

Auscultation 373 

General  and  Local  Symptoms  of  Diseases  of  the  Heart 381 

Cardiac  Dropsy 382 

Derangement  of  the  Grculation 382 


CONTENTS.  9 

PAGE 

Cardiac  Pain 383 

Palpitation  386 

Functional  Disorders  of  the  Heart 388 

Disorders  characterized  by  Palpitation,  associated  or  not  with  Change 

of  Rhythm 388 

Organic  Diseases  of  the  Heart 393 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Region  ;  the  Symptoms 
of  a  Disturbed  Circulation ;  and  a  Change  in  the  Sounds  of  the 

Heart,  or  their  Replacement  by  Murmurs 393 

Acute  Endocarditis 394 

Acute  Pericarditis 399 

Myocarditis 407 

Chronic  Diseases  attended,  with  Increased  Extent  of  Percussion  Dulness,  but 

with  Normal  or  almost  Normal  Heart-Sounds 409 

Hypertrophy 409 

Dilatation 412 

Fatty  Degeneration '. 414 

Pericardial  Effusion 416 

Diseases  of  the  Heart  exhibiting  more  or  less  of  the  Signs  and  Symptoms  of 

Enlargement  of  the  Organ,  and  accompanied  by  Endocardial  Murmurs  417 

Valvular  Affections 417 

Displacements  of  the  Heart 431 


SECTION  III. 

Thoracic  Aneurism 432 

CHAPTEE  Y. 

DISEASES    OP    THE   MOUTH,  PHARYNX,  AND    (ESOPHAGUS. 

Mouth 443 

Fauces 445 

Tonsillitis 446 

Diphtheria 447 

Mumps    455 

Chronic  Sore  Throat 456 

Pharynx  and  QEsophagus 458 

CHAPTER   VI. 

DISEASES   OF   THE   ABDOMEN. 

General  Considerations 462 

Methods  and  General  Results  of  Physical  Examination  of  the  Abdomen 462 

Inspection 462 

Palpation 464 

Percussion 465 

Auscultation 470 


10  CONTENTS. 

SECTION  I. 

DISEASES  OF  THE  STOMACH. 

PAGE 

General  Considerations 47O 

Loss  of  Appetite 475 

Excessive  Acidity  of  tlie  Stomach 476 

Flatulency 477 

Nausea  aiad  Vomiting 478 

Pain 484 

Diseases  of  the  Stomach  in  which  Pain  and  Soreness  at  the  Epigastrium,  and 

Vomiting,  occur 489 

Acute  Gastritis 489 

Chronic  Diseases  attended  with  Pain,  Epigastric  Tenderness,  and  Vomiting. .  491 

Chronic  Gastritis 49I 

Gastric  Ulcer 493 

Gastric  Cancer : 497 

Dilatation  of  the  Stomach 505 

Hour-Glass  Stomach 508 


SECTION  II. 

DISEASES    OP   THE   INTESTINES   AND    OP   THE   PERITONEUM. 

General  Considerations 508 

Alvine  Discharges 509 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to  the  Middle  or 
Lower  Part  of  the  Abdomen,  and  not  associated  with  Marked  Tender 

ness  or  with  Fever 512 

Colic 512 

Diseases  attended  with  Pain  and  Marked  Tenderness  in  the  Umbilical  Eegion 

or  diffused  over  the  Abdomen 520 

Acute  Enteritis : 520 

Acute  Peritonitis 522 

Chronic  Peritonitis 531 

Diseases  attended  with  Pain  and  tenderness  in  the  Right  Iliac  Fossa 532 

Appendicitis 532 

Disorders  attended  with  Constipation,  and  of  which  it  is  a  Prominent  Symp- 
tom     540 

Intestinal  Obstruction 540 

Habitual  Constipation 550 

Disorders  in  which  Morbid  Discharges  from  the  Bowels  occur 553 

Diarrhoea 553 

Dysentery 556 

Intestinal  Hemorrhage,  or  Melaena 559 

Fatty  Diarrhoea .' 560 

Diseases  attended  with  Vomiting  and  Purging 561 

Cholera  Infantum 561 

Cholera  Morbus 562 

Cholera 563 


CONTENTS.  11 
SECTION  III. 

DISEASES   OF  THE   LIVER. 

PAGE 

General  Considerations 567 

Jaundice 567 

Acute  Diseases  of  the  Liver  attended  generally  with  Slight  Enlargement  of 

the  Organ,  and  with  more  or  less,  though  rarely  much.  Jaundice.  . . .  572 

Acute  Congestion 572 

Acute  Hepatitis 572 

Inflammation  of  the  Gall-Bladder  and  Gall-Ducts 577 

Acute  Cholecystitis 580 

Acute  Cholangitis 582 

Acute  Diseases  characterized  by  a  Decrease  in  the  Size  of  the  Liver  and  by 

Deep  Jaundice 582 

Acute  Yellow  Atrophy 582 

Chronic  Diseases  attended  with  Enlargement  of  the  Liver,  and  with  slight  or 

no  Jaundice 584 

Chronic  Congestion 584 

Chronic  Hepatitis 586 

Abscess  of  the  Liver 586 

Fatty  Liver 592 

Waxy  Liver 592 

Cancer  of  the  Liver 593 

Hydatids  of  the  Liver 600 

Chronic  Diseases  attended  with  Decreased  Size  of  the  Liver,  and  with  Ab- 
dominal Dropsy 604 

Cirrhosis 604 

Chronic  Atrophy  of  the  Liver 610 

SECTION  IV. 

ABDOMINAL   ENLARGEMENT. 

General  Abdominal  Enlargement • 610 

Ascites 610 

Partial  Abdominal  Enlargement 617 

Abdominal  Tumors 617 

SECTION  V. 

ABDOMINAL   PULSATION. 

Aortic  Pulsation 628 

Abdominal  Aneurism 629 

CHAPTEE  YII. 

ON    THE   URINE,  AND    ON    DISEASES   OF   THE    URINARY   ORGANS. 

Urine 632 

Color 635 

Specific  Gravity 636 

Eeaction 637 

Changes  in  the  Quantity  of  the  more  Important  Constituents 638 


12  ■  CONTENTS. 

PAGE 

Presence  of  Abnormal  Substances  in  the  Urine 650 

Sediments 671 

Urinary  Organs 675 

Diseases  of  the  Kidney  of  which  Pain  is  a  Prominent  Symptom 675 

Acute  Painful  Nephritis 675 

Nephralgia 676 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine,  associated  with 

more  or  less  Dropsy 680 

Acute  Bright's  Disease 681 

Chronic  Bright's  Disease 688 

Diseases  associated  with  Purulent  Urine 700 

Acute  Cystitis 700 

Chronic  Cystitis 701 

Abscess  of  the  Kidney 702 

Pyelitis 704 

Disorders  in  which  a  very  large  Amount  of  Urine  is  discharged 707 

Diabetes 707 

Chronic  Diuresis 711 

Disorders  in  which  little  or  no  Urine  is  discharged 712 

Suppression  of  Urine 712 

Retention  of  Urine 713 

CHAPTEE   YIII. 

DROPSY. 

Dropsy,  according  to  its  Seat  and  Extent 715 

Dropsy,  according  to  its  Causation 716 

CHAPTEE   IX. 

DISEASES    or    THE    BLOOD-VESSELS. 

Diseases  of  the  Arteries 719 

Arteritis 719 

Atheromatous  Changes 721 

Diseases  of  the  Veins 721 

Phlebitis 721 

Diseases  of  the  Capillaries 722 

CHAPTEE  X. 

DISEASES    OF   THE   BLOOD. 

General  Considerations 724 

Ansemia 737 

Pernicious  Ansemia 740 

Leucocytosis 745 

Leukaemia 746 

Addison's  Disease • , 751 

Pyaemia 754 

Septicaemia 757 

Thrombosis  and  Embolism 759 

Scurvy 764 

Purpura 765 


CONTENTS.  13 
OHAPTEE   XI. 

RHEUMATISM    AND    GOUT. 

PAGE 

Acute  Rheumatism 768 

Chronic  Eheumatism 772 

Gout 775 

Artliritis  Deformans 778 

Rickets 780 

CHAPTEE   XII. 

FEVERS. 

General  Considerations 783 

Continued  Fevers 784 

Simple  Continued  Fever 784 

Catarrhal  Fever 785 

Typhoid  Fever 789 

Typhus  Fever 807 

Cerebro-spinal  Fever 812 

Relapsing  Fever 819 

Yellow  Fever 823 

Dengue 828 

Plague 830 

Malta  Fever 831 

Glandular  Fever 833 

Periodical  Fevers 833 

Intermittent  Fever 836 

Remittent  Fever 841 

Pernicious  or  Congestive  Fever 846 

Typho-Malarial  Fever 852 

Eruptive  Fevers 853 

Scarlet  Fever 853 

Measles 858 

Rubella 861 

Smallpox 864 

Erysipelas 868 

CHAPTEE  XIII. 

DISEASES   OF   THE    SKIN. 

General  Considerations 871 

Erythematous  Diseases 873 

Papular  Diseases 875 

Vesicular  Diseases 877 

Bullous  Diseases 879 

Pustular  Diseases 880 

Squamous  Diseases 882 

Maculae 884 

New  Growths 884 

Hypertroi^hies 886 


14  CONTENTS. 

PAGE 

Parasitic  Diseases 888 

Altered  Gland-secretions 891 

Nervous  Affections 892 


CHAPTEE  XIY. 

POISONS    AND    PARASITES. 

Poisons ; 893 

Acute  Poisoning 893 

Irritant  Poisons 893 

Narcotic  Poisoning 897 

Chronic  Poisoning 902 

Parasites 911 

Vegetable  Parasites 911 

Animal  Parasites 913 

Index 927 


LIST    OF    ILLUSTRATIONS. 


FIG.  PAGE 

1.  Sphygmograph  of  Marey 35 

2.  Dudgeon's  Sphygmograph 35 

3.  Sphygmogram  enlarged 36 

4.  Self-registering  Thermometer 39 

5.  SegTiin's  Surface  Thermometer 39 

6.  Surface  Thermometer,  with  coil  at  ex- 

tremity    39 

7.  Temperature  Chart  in  Simple  Continued 

Fever 41 

8.  Temperature  Chart  from  a  Case  of  Re- 

mittent Fever 42 

9.  The  Centres  in  the  Human  Brain  ....  52 

10.  Right  Homonymus  or  Lateral  Hemia- 

nopsia      53 

11.  The  ^sthesiometer  of  Sieveking  ....  68 

12.  Carroll's  ^sthesiometer 69 

13.  Mathieu's  Dynamometer 94 

14.  Hutchinson's  Teeth 123 

15.  Laryngoscopes 235 

16.  Laryngoscopic  Examination 236 

17.  Laryngeal  Image,  as  seen  in  the  Laryn- 

goscope    237 

18.  The  Stethometer 264 

19.  The  Stethogoniometer 265 

20.  The  Pleximeter 266 

21.  Percussion  Hammer 267 

22.  Hawksley's  Stethoscope 272" 

23.  The  Double  Stethoscope    .......  272 

24.  The  Phonendoscope 273 

25.  Diagram  illustrative  of  the  Main  Forms 

of  Feeble  Respiration 276 

26.  Diagram  illustrative  of  Rftles 281 


4 

FIG.  PAGE 

27.  Elastic  Fibres  of  Pulmonary  Tissue    .  .  296 

28.  A  Spiral  Magnified .  296 

29.  Charcot-Leyden  Crystals 297 

30.  Tubercle  Bacilli  (in  colors)     299 

31.  Casts  from  a  Case  of  Plastic  Bronchitis  .  .308 

32.  Appearance  of  the  Chest  in  Emphysema  310 

33.  Beginning  Infiltration  in  Phthisis    ...  316 

34.  Cavities  in  the  Lung  in  Phthisis    ....  318 

35.  Temperature  Chart  in  Pneumonia  ...  335 

36.  Diagram  illustrative  of  Perfect  Pulmo- 

nary Consolidation,  such  as  happens 

in  the  Second  Stage  of  Pneumonia  .  .    337 

37.  Temperature  Chart   in    Broncho-Pueu- 

monia  (in  colors) 343 

38.  Diplococcus  Pneumoniae  of  Fraenkel  .   .    344 

39.  Pneumococcus  (Diplococcus)  of  Fried- 

laender 345 

40.  Roughening  of  the  Pleura  from  Inflam- 

mation        847 

41.  Large  Effusion  occupying  the  Left'Pleu- 

ral  Cavity 348 

42.  Physical  Signs  in  Pneumothorax  .   .  .  '.  354 

43.  Topography  of  the  Heart 36& 

44.  Diagram  shomng  the  Points  at  which 

the  Separate  Valves  may  be  listened  to   374 

45.  Position  of  the  Heart,  and  Distention  of 

the  Pericardium  with  Fluid,  in  Peri- 
carditis   400 

46.  Hypertrophied  Heart,  lying  in  its  Posi- 

tion in  the  Chest 410 

47.  Dilated     Heart,    the    Right    Ventricle 

opened 413 

15 


16 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

48.  Narrowing    of   the    Aortic   Orifice    by 

Vegetations 422 

49.  Insufficient   Mitral   Valves   permitting 

Regurgitation  of  tlie  Blood 423 

50.  Sphygmogram  of  Aortic  Insufficiency  .  425 

51.  Sphygmogram  of  Mitral  Regurgitation  425 

52.  Klebs-Loeffler  Bacilli 448 

53.  Results  of  Abdominal  Percussion    ...  468 

54.  Sarcinse  Ventriculi 480 

55.  Comma  Bacillus  of  Koch,  from  Culture 

in  Blood-Serum 564 

56.  Doremus's  Ureometer 640 

57.  Greene's  Ureometer 640 

58.  Crystals  of  Uric  Acid 642 

59.  Mixed  Urates     644 

60.  Earthy  Phosphates  in  the  Urine    ....  646 

61.  Calcium  Oxalate  Crystals 651 

62.  Albumin  Test-Glass 660 

63.  Leucocytes  in  the  Urine 669 

64.  Epithelial  Casts  and  Cells  from  the  Kid- 

neys in  a  Case  of  Acute  Bright's  Dis- 
ease      681 

65.  Fatty  Casts  and  Epithelial  Cells  filled 

with  Fat,  as  seen  in  Discharge  from 

a  Fatty  Kidney 694 

66.  Hyaline  or  Waxy  Casts  from  the  Urine  .   695 

67.  Granular  Casts,  or  Casts  covered  with 

Disintegrating  Epithelium  and  Gran- 
ules      697 

68.  Potain's  Pipette 726 


FIG.  PAGE 

69.  Blood-Mixture,  as  seen  with  the  Square 

Micrometer    Ruling    of    the    Moist- 
Chamber  of  Malassez 727 

70.  Daland's  Hsematokrite 728 

71.  Hsemoglobinometer  of  Gowers 730 

72.  Chart  showing  Blood-Changes  in  Chlo- 

rosis      737 

73.  Blood  in  Pernicious  Ansemia 742 

74.  Temperature  in  a  Case  of  Influenza    .   .  788 

75.  Temperature  in  Typhoid  Fever 791 

76.  Eberth  Typhoid-Fever  Bacillus,  from  a 

Potato  Culture 793 

77.  Diplococcus  Intfacellularis 815 

78.  Spirilla  of  Relapsing  Fever 822 

79.  Temperature  in  Yellow  Fever 825 

80.  Temperature   in   Tertian   Intermittent 

Fever 837 

81.  Temperature  Chart  in  Remittent  Fever    842 

82.  Pigment  in  the  Blood  in  Malarial  Ca- 

chexia     851 

83.  Temperature  in  Variola 865 

84.  Temperature  in  Varioloid 867 

85.  Temperature  Chart  in  Facial  Erysipelas  869 

86.  Acarus  Scabiei 889 

87.  Segments  of  Taenia  Solium 915 

88.  Heads  of  Taeniae 915 

89.  Trichina  in  Recent  Human  Muscle     .   .  920 

90.  Trichina  Spiralis.    Magnified  300  times  .  921 

91.  Trichina   Capsule  with  Shell-like  Cal- 

careous Deposits 922 

92.  Encapsuled  Chalky  Concretions  in  Mus- 

cle, due  to  Dead  Trichinae 922 


MEDICAL    DIAGNOSIS. 


INTRODUCTION. 

GENERAL   CONSIDERATIONS. 

The  study  of  any  complicated  subject  leads  of  necessity  to  its 
arrangement  into  branches.  Closely  connected  as  these  are,  and  form- 
ing always  parts  of  a  whole,  they  are  not  only  capable  of  distinct 
treatment,  but  frequently  become  more  intelligible  as  they  are  so 
treated.  This  is  made  very  manifest  in  investigating  disease.  The 
extent  of  ground  covered  by  the  inquiry  has  rendered  it  imperative 
to  map  it  out  into  various  provinces,  which,  however  intimately 
united,  may  be  with  convenience  separately  surveyed.  One  com- 
prises the  laws  and  facts  common  to  individual  affections  ;  in  another 
is  gathered  together  all  relating  to  their  causes  ;  another  embraces 
the  consideration  of  their  detection  and  the  full  recognition  of  their 
nature.  It  is  the  purpose  of  these  pages  to  examine  this  department 
somewhat  minutely,  and  especially  that  portion  of  it  coming  within 
the  range  of  the  practitioner  of  medicine.  In  so  doing  it  will  become 
apparent  how  diagnosis,  for  such  the  distinction  of  disease  is  techni- 
cally called,  is  partly  a-  science,  partly  an  art ;  a  science,  because  it 
comprehensively  takes  account  of  general  facts,  and  of  principles 
based  on  those  facts ;  an  art,  because  it  demands  a  cognizance  of  the 
means,  and  their  application  to  arrive  at  the  desired  result. 

To  consider,  then,  medical  diagnosis  in  all  its  bearings,  it  will  be 
necessary  not  only  to  hold  up  to  view  the  morbid  states  met  with  in 
the  examination  of  the  sick,  but  also  to  inquire  in  what  manner  they 
may  be  most  readily  recognized  and  explored,  and  how  their  differ- 
ences may  be  made  available  in  the  discrimination  of  one  ailment  from 
another.  In  a  study  of  this  kind,  an  investigation  of  symptoms  plays 
unavoidably  a  prominent  part.     In  truth,  the  detection  of  disease  is 

•^       -^  2  .  17 


18  MEDICAL  DIAGNOSIS. 

the  product  of  close  observation  of  symptoms,  and  of  correct  de- 
duction from  tliese  symptoms. 

The  first  requirement  therefore  for  an  accurate  diagnosis  is  to  learn 
to  recognize  morbid  signs.  But  the  art  of  observation  this  implies  is 
not  easy,  and  cannot  be  thoroughly  acquired  except  by  practice.  No 
one  aspiring  to  become  a  skilful  observer  can  trust  exclusively  to  the 
light  reflected  from  the  writings  of  others  ;  he  must  carry  the  torch 
in  his  own  hands,  and  himself  look  into  every  recess.  The  knowl- 
edge obtained  from  reading  is,  however,  serviceable  in  this  way :  it 
aids  in  overcoming  one  of  the  main  difficulties  at  first  experienced, — 
to  know  where  to  look  and  what  to  look  for.  There  are  in  almost 
every  affection  some  symptoms  which  can  hardly  escape  the  merest 
beginner ;  but  also  some  which  do  not  appear  on  the  surface,  and 
which  to  find  taxes  the  skill  of  the  experienced  physician.  And  it  is 
especially  in  this  search  after  hidden  signs  that  medical  information  as 
well  as  cultivated  tact  is  demanded. 

Now,  to  recognize  the  manifestations  of  disease,  whether  they 
are  or  are  not  readily  perceptible,  we  have  to  employ  our  eyes  and 
ears,  our  sense  of  touch  and  of  smell.  Formerly  we  could  go  no 
farther  than  these  senses  unassisted  would  carry  us.  But  science 
has  lent  its  aid,  and  furnished  means  by  the  help  of  which  we  can 
detect  clearly  what  before  we  could  not  detect  at  all,  or  of  which  at 
best  we  caught  only  a  glimpse.  We  now  possess  instruments  of  pre- 
cision by  which  we  ascertain  with  accuracy  the  size  of  organs  and 
their  play.  With  thermometers  we  tell  the  degree  of  heat  of  various 
parts  of  the  body.  Specific-gravity  bottles,  and  other  measures  de- 
vised for  the  purpose,  inform  us  of  the  relative  gravity  of  fluids. 
The  microscope  gives  at  a  glance  insight  into  matters  which  the 
naked  eye  fails  even  to  perceive,  shows  us  crystals  in  secretions,  en- 
ables us  to  count  the  corpuscles  in  the  blood,  and  to  detect  minute 
and  disease-causing  specific  organisms.  The  laryngoscope  demon- 
strates the  appearance  and  the  movements  of  the  organ  of  speech. 
The  ophthalmoscope  informs  us  of  the  state  of  the  vessels  in  the  brain. 
And  chemistry  is  rendering  our  knowledge  of  many  morbid  states 
amazingly  complete.  Then  the  sagacity  of  comparatively  modern 
times  has  taught  us  how  a  disciphned  ear  may  detect  the  workings 
of  disease  in  cavities  into  which  the  eye  cannot  penetrate ;  and  with 
the  marvel  of  the  Rontgen  rays  we  can  now  see  what  is  going  on  in 
the  interior  of  the  body.  The  effect  of  all  these  improved  methods 
of  study  has  been  to  give  an  immense  impetus  to  clinical  research, 
and  to  lead  to  the  construction  of  a  solid  groundwork,  in  striking 
contrast  with  the  looseness  of  former  times.     The  advance  in  diag- 


GENERAL   CONSIDERATIONS.  19 

nosis  thus  attained  forms,  indeed,  one  of  the  most  pleasing  portions 
of  medical  history. 

When,  by  means  of  the  aided  or  unaided  senses,  the  symptoms 
of  the  malady  have  been  discovered,  the  next  step  towards  a  diag- 
nosis is  a  proper  appreciation  of  their  significance  and  of  their  rela- 
tion towards  one  another.  Knowledge  and,  above  all,  the  exercise 
of  the  reasoning  faculties  are  now  indispensable.  The  daily  habit  of 
investigating  disease  ;  a  scrutinizing  study  of  the  anatomical  lesions ; 
chemistry,  with  its  most  searching  analyses  ;  the  microscope,  with  the 
wonders  it  reveals,  are  all  of  little  use,  unless  we  have  been  taught 
the  necessity  of  placing  in  connection  with  one  another  the  morbid 
signs  they  lay  bare,  and  of  considering  in  individual  cases  their 
respective  value.  Were  it  otherwise,  the  science  of  diagnosis  would 
be  simply  a  matter  of  memory.  It  is,  however,  this  very  analysis  of 
symptoms  and  the  lengthy  process  of  induction  attending  it  which 
make  medical  diagnosis  so  difficult.  Nor  is.  it  reasoning  on  the 
ascertained  facts  alone  that  is  required ;  the  premises  may  be  but 
probabilities  ;  for,  in  truth,  diagnosis  deals  at  times  with  the  logic  of 
probabilities  as  much  as  with  the  logic  of  patent  facts. 

Now,  we  are  greatly  aided  in  appreciating  morbid  signs,  and  in  in- 
terpreting them  correctly,  by  already  existing  knowledge.  We  look 
to  landmarks  which  our  predecessors  have  erected,  and  the  gradually 
accumulated  science  of  semeiology,  rightly  employed,  furnishes  the 
clue  to  the  discovery  of  the  disease.  Thus  the  stores  which  medicine 
has  laboriously  collected  during  centuries  can  be  used  with  advantage 
by  all,  and  exist  for  the  good  of  all.  But  besides  this  knowledge,  the 
laboratory,  with  its  facilities  for  solving  new  and  obscure  clinical 
problems,  is  of  immense  and  constantly  growing  advantage. 

But  an  acquaintance  with  semeiology  is  far  from  being  the  sole 
guide  to  diagnosis,  nor  does  it  at  once  help  to  a  recognition  of  the 
malady.  There  are  few  symptoms  in  themselves  distinctive ;  and 
often  a  symptom  may  be  due  to  one  of  several  causes.  Semeiology 
informs  us  of  these  different  causes  ;  but  to  find  out  the  precise  mean- 
ing of  the  abnormal  manifestation  in  an  individual  case,  we  have  to 
draw  our  inference  from  all  the  signs  encountered ;  to  compare  them 
with  one  another ;  to  seek  out  those  that  are  in  the  background.  We 
are  thus  arriving,  step  by*  step,  at  the  explanation  of  the  morbid  ap- 
pearances, the  starting-point  in  deduction  always  being  what  is  known 
of  the  affection  the  presence  of  which  is  suspected,  and  the  symptoms 
of  which  we  are  contrasting  with  those  before  us.  For  the  conclusion 
to  be  valid  and  exact,  it  is  of  course  requisite  that  each  part  of  the 
testimony  have  the  proper  position  assigned  to  it.     In  reasoning  cor- 


20  MEDICAL   DIAGNOSIS. 

rectly  on  symptoms,  the  same  laws  apply  as  in  reasoning  correctly  on 
any  other  class  of  phenomena :  the  facts  have  to  be  sifted  and 
weighed,  not  merely  indiscriminately  collected.  And  while  this  in- 
tellectual act  is  being  performed,  much  collateral  evidence  is  to  be 
sought  before  a  final  judgment  is  given ;  especially  is  it  necessary  to 
view  the  symptoms  "with  constant  reference  to  the  age,  sex,  and 
habits  of  the  patient,  and  to  the  circumstances  amid  Avhich  the  dis- 
order develops. 

To  accomplish  all  this  effectually,  the  physician  has  need  of  much 
and  varied  knowledge.  He  must  be  master  of  something  more  than 
of  the  information  supplied  to  him  by  semeiology.  He  must  be  an 
anatomist  to  pronounce  with  certainty  on  the  seat  of  the  malady ;  a 
physiologist  to  appreciate  the  state  of  the  great  centres  and  the  aber- 
ration of  function.  Above  all,  he  must  be  a  pathologist  in  the  full 
sense  of  the  term :  he  must  understand  the  antagonism  between  dis- 
eases ;  the  frequency  with  which  they  coexist ;  the  influence  of  re- 
medial agents  on  them ;  and  be  cognizant  of  their  natural  history  and 
of  the  general  laws  governing  them, — for  how  else  can  he  form  an 
estimate  of  morbid  action  while  in  progress  ?  Then  it  is  desirable  that 
he  should  be  aware  of  what  are  their  current  divisions  and  classifica- 
tions. From  what  has  already  been  represented,  it  is  evident  that  he 
must  also  be  a  correct  reasoner ;  for  even  a  good  observer  will,  by  bad 
reasoning,  arrive  at  a  faulty  diagnosis ;  just  as  sometimes  a  bad  ob- 
server may,  by  the  same  process,  blunder  into  the  truth.  There  is, 
indeed,  no  end  to  the  extent  of  knowledge  which  may  be  brought  to 
bear  in  working  out  a  conclusion  regarding  the  character  and  seat  of 
a  malady.  The  habit  of  observation  once  acquired,  information  of 
the  most  varied  kind  will,  by  an  accurate  reasoner,  be  made  tributary 
to  the  completeness  of  the  diag-nosis.  Every  fresh  acquirement  tends 
io  enlarge  our  powers  of  insight.  Just  as  in  nature,  the  higher  we 
ascend,  the  more  fully  lies  the  view  before  us. 

Ha^dng  thus  indicated  the  elements  of  a  thorough  diag'nosis,  we 
may  next  inquire  in  what  way  tliis  is  most  easily  arrived  at  when  at 
the  bedside.  The  main  facts  of  the  case  on  which  the  deductions  are 
to  be  based  are  of  course  first  elicited.  We  lay  hold  of  these  main 
facts,  and  especially  of  those  that  are  the  most  direct  signs  of  the 
morbid  action.  They  are  coupled  together,' and  the  inquiry  is  started 
as  to  what  organ  they  indicate  as  the  seat  of  the  malady.  This  often 
has  been  already  determined  by  the  very  method  of  the  examination ; 
and  we  therefore  proceed  at  once  to  investigate  the  precise  nature  of 
the  disorder  by  analyzing  the  symptoms  and  the  pre^vdous  history. 
Sometimes,  however,  the  site  of  the  disease  does  not  admit  of  being 


GENERAL   CONSIDERATIONS.  21 

definitely  fixed  upon,  or  we  can  only  in  a  general  manner  decide  upon 
the  function  impaired.  Again,  as  in  idiopathic  fevers,  we  may  find 
no  signs  of  local  disease, — merely  those  of  a  general  disturbance.  In 
any  of  these  instances  clinical  experience  steps  in  to  explain  the 
phenomena  as  far  as  possible,  and  to  inform  us  in  what  affections 
they  occur.  It  may  be  only  in  one  ;  then  the  desired  goal  is  at  once 
attained.  But,  as  above  stated,  there  are  few  signs  in  themselves 
pathognomonic.  It  is  therefore  to  be  ascertained  which  one  of  the  dis- 
orders is  before  us  that  special  pathology  teaches  may  yiejd  the  symp- 
toms encountered.  One  of  these  is  taken  up.  Its  symptoms  are  placed 
side  by  side  with  those  present.  They  accord  in  some  respects,  but 
not  in  all.  Moreover,  in  searching  for  some  of  the  phenomena  which 
the  supposed  malady  gives  rise  to,  these  are  not  found.  The  view  is 
abandoned  and  another  taken  up.  It  agrees  in  all  particulars.  The 
diagnosis  is  made.  Yet,  when  the  diagnosis  is  thus  arrived  at,  we 
have  still  to  determine,  before  it  can  be  considered  as  complete  and 
can  be  acted  upon,  whether  or  not  any  other  morbid  state  exists,  and 
to  take  into  account  the  patient's  general  condition  and  his  indi- 
viduality. 

To  cite  a  case  in  illustration.  A  person  consults  us  for  a  cough 
brought  on  by  exposure.  He  has  been  ill  for  four  or  five  days,  having 
been  previously  in  good  health.  We  notice,  on  examining  him,  that 
his  breathing  is  hurried,  and  that  he  has  fever ;  the  lower  portion  of 
one  side  of  the  chest  is  dull  on  percussion,  and  the  respiration  there 
is  wanting ;  the  action  and  sounds  of  the  heart  are  normal.  The 
facts  point  to  the  lung  or  its  covering  as  the  seat  of  the  malady.  We 
know,  furthermore,  from  the  history  and  the  febrile  symptoms,  that 
we  have  to  deal  with  an  acute  affection.  What  are  the  acute  pul- 
monary affections  ?  Acute  bronchitis  ;  acute  phthisis  ;  acute  pleurisy  ; 
acute  pneumonia.  In  all  occur  fever,  cough,  and  disordered  breath- 
ing. Is  it  acute  pneumonia  ?  No  ;  for,  nothwithstanding  there  is  in  this 
complaint,  in  addition  to  the  general  symptoms  mentioned,  dulness 
on  percussion,  the  dulness  is  associated  with  a  blowing  respiration  ; 
whereas  in  the  case  before  us  no  respiration  is  heard.  Let  us  look  at 
the  sputum,  and  see  if  it  be  tenacious  and  rusty-colored.  It  is  not ; 
it  is  thin  and  frothy.  But  acute  pleurisy  may  explain  all  the  signs. 
The  patient,  too,  when  questioned,  states  that  he  had  at  the  onset  a 
sharp  pain  in  his  side  ;  and  this,  we  are  aware,  takes  place  in  pleurisy. 
The  vocal  vibrations,  likewise,  are  noticed  to  be  absent  on  the  affected 
side  of  the  chest,  which,  when  measured,  is  found  to  be  enlarged. 
This  corresponds  in  all  points  with  what  happens  in  pleurisy  in  the 
stage  of  effusion.     The  disease  is,  therefore,  acute  pleurisy  in  the 


22  MEDICAL  DIAGNOSIS. 

stage  of  effusion.  We  finish  the  diagnosis  by  ascertaining  the  exist- 
ence or  non-existence  of  other  maladies,  and  by  taking  note  of  the 
severity  of  the  complaint ;  that  it  has  occurred  in  a  young  and  robust 
person  of  good  habits  ;  and  that  the  symptomatic  fever  is  very  active. 

This  process  of  arriving  at  an  opinion  is  the  simplest.  It  is  one 
in  which  the  investigation  of  the  case  is  to  some  extent  carried  on 
v^hile  the  deductions  are  being  made.  And  it  is  astonishing  how 
rapidly  it  may  be  performed  by  habit.  The  mind  works  uncon- 
sciously, and»a  decision  is,  to  all  appearance,  formed  intuitively,  Avhich 
surprises  the  inexperienced  by  its  readiness  and  precision.  This 
method  aims,  so  far  as  the  symptoms  permit,  at  a  direct  diagnosis. 
But,  in  truth,  it  is  often  what  is  called  differential, — that  is,  it  takes 
cognizance  of  and  dwells  on  the  essential  signs  by  which  one  disease 
can  be  discriminated  from  another  resembling  it. 

Sometimes,  instead  of  attaining  the  desired  result  in  the  manner 
proposed,  we  are  obliged  to  judge  of  the  nature  of  the  malady  en- 
tirely by  finding  out  what  it  is  not.  The  various  diseases  capable  of 
producing  all,  or  even  some,  of  the  striking  symptoms  observed,  are 
enumerated.  They  are  one  by  one  considered  and  set  aside,  until 
by  this  process  of  pure  exclusion  the  mischief  is  brought  to  light. 
Thus,  to  use  again  the  example  just  given,  we  should  have  to  assign 
reasons  why  the  disease  is  neither  acute  pneumonia,  nor  bronchitis 
nor  acute  phthisis,  and  in  this  way  determine  it  to  be  acute  pleurisy. 
But  to  prove  what  a  thing  is  by  proving  all  that  it  is  not  is  a  very 
tedious  process,  and  we  must  be  quite  certain  that  really  all  morbid 
states  which  may  give  rise  to  the  symptoms  encountered  are  thought 
of  and  inquired  into ;  otherwise  our  conclusion  may  be  fallacious, 
though  reasoned  out  in  the  most  logical  manner.  Moreover,  our 
knowledge  of  many  pathological  conditions  is  so  imperfect  that  we 
are  not  fully  cognizant  of,  or  able  at  once*  to  discern,  the  more  char- 
acteristic signs  ;  nor  can  the  symptoms  be  taken  hold  of  and  ar- 
ranged in  such  a  way  as  shall  permit  us  to  make  nice  distinctions 
without  a  lengthy  and  laborious  plan  of  procedure.  Owing  to  these 
drawbacks,  diagnosis  hy  exclusion  is  not,  on  ordinary  occasions,  much 
employed,  nor,  indeed,  is  it  to  be  recommended.  Yet  in  difficult  and 
obscure  cases,  where  the  accustomed  pathway  is  blocked  up,  it  may 
enable  us  to  pass  by  obstacles  otherwise  insurmountable. 

But  can  we  by  this  or.  by  any  other  road  always  reach  a  certain 
diagnosis?  We  cannot,  and  for  several  reasons.  The  patient  may 
deceive  us,  wilfully  or  unintentionally.  It  may  be  necessary,  for  the 
confirmation  of  the  opinion  formed,  to  obtain  an  accurate  history  of 
the  case,  and  circumstances  may  render  this  impossible.     The  dis- 


GENERAL   CONSIDEBATIONS.  23 

order  may  be  so  rare  that  its  symptoms  are  not  understood.  There 
may  be  several  lesions  present,  the  signs  of  one  masking  or  neutral- 
izing the  signs  of  the  other. 

The  first  of  the  causes  mentioned  is  a  source  of  error  difficult  to 
guard  against.  To  escape  punishment,  to  avoid  disagreeable  duty, 
to  excite  compassion,  to  obtain  a  compliance  with  unreasonable 
wishes,  or  sometimes  from  the  mere  love  of  deception,  symptoms 
may  be  stated  to  exist  which  do  not  exist,  or  may  be  imitated  and 
artificially  produced.  Persons  who  thus  feign  disease  are  numerous. 
They  are  found  in  all  occupations  and  in  all  classes  of  society.  They 
abound  in  the  army  and  navy.  Hysterical  women  and  hypochondriacs 
help  to  swell  the  list.  These,  indeed,  suffer  mostly  some  inconveni- 
ence, but  exaggerate  it  immensely,  and,  by  deceiving  themselves,  end 
by  deceiving,  unless  he  be  on  his  guard,  their  physician.  On  the 
other  hand,  disease  actually  in  progress  may  be  carefully  concealed 
from  motives  of  delicacy  or  from  fear  of  the  consequences. 

An  incorrect  diagnosis  from  want  of  a  proper  history  does  not,  on 
the  whole,  occur  often.  Patients  are  generally  very  willing  to  give  a 
full  account  of  themselves  and  of  their  distresses.  Sometimes,  how- 
ever, the  reverse  happens.  Pain  or  mental  anxiety  and  sorrow  may 
be  wearing  the  body  out  while,  the  sufferer  obstinately  persists  in 
hiding  the  cause  of  his  waning  health.  We  meet  also  with  indi- 
viduals so  stupid  that  the  most  elaborate  cross-examination  fails  to 
elicit  anything  like  a  connected  history.  Again,  we  may  be  unable  to 
do  so  from  the  patient  having  lost  the  power  of  speech  or  being 
unconscious. 

In  the  rarity  of  a  disease  we  have  a  serious  drawback  to  its  recog- 
nition. This  may  occasion  an  error  of  diagnosis  in  a  twofold  man- 
ner. The  more  distinctive  symptoms  may  be  so  little  understood, 
and  the  prominent  features  be  so  nearly  identical  with  those  of  a 
malady  with  the  manifestations  of  which  w^e  are  well  acquainted, 
that  a  conclusion  of  the  presence  of  the  latter  forces  itself  almost 
immediately  on  the  mind.  Or,  the  disorder  may  give  rise  to  phe- 
nomena wholly  unknown,  nothing  but  the  autopsy  revealing  their 
true  meaning.  Every  physician  encounters  such  cases.  It  is  true 
that  the  progress  of  science  and  the  aggregation  of  cHnical  facts  are 
from  year  to  year  bringing  them'  into  a  narrower  circle.  Yet,  are 
there  not  still  diseases,  nay,  groups  of  diseases,  that  have  eluded  dis- 
covery to  the  manifold  means  of  research  of  the  present  day,  as  they 
have  to  the  accumulated  experience  of  the  past  ? 

But  the  most  serious  obstacle  to  a  precise  diagnosis  lies  in  the  fact 
that  frequently  lesions  coexist.     Disease  is  a  very  complex  state,  and 


24  MEDICAL  DIAGNOSIS. 

when  one  portion  of  the  economy  gets  out  of  order,  another  is  apt  to 
follow.  Then  a  part  contiguous  to  one  chronically  affected  may  be 
attacked  with  acute  disease ;  or  remote  sympathetic  derangements 
become  very  prominent.  A  thorough  exammation  of  the  case  is  the 
only  safeguard  against  error. 

These,  then,  are  the  various  causes  which  render  a  chagnosis  un- 
certain, or  wholly  unattainable.  Let  us  add  to  them  one  that  does  so 
temporarily.  There  are  disorders  the  early  manifestations  of  which 
are  so  much  alike  that  it  is  next  to  impossible  to  tell  with  wliich  of 
several  we  have  to  deal.  In  fevers  this  often  happens.  Here,  how- 
ever, a  few  days  will  almost  always  solve  the  difficulty.  But  not  so 
in  other  diseases.  It  is  only  after  a  much  longer  period  that  the 
appearance  or  disappearance  of  a  striking  symptom,  or  the  greater 
prominence  a  liitherto  mdistinct  sign  assumes,  enables  us  to  reach  a 
decision. 

In  some  such  instances,  the  treatment  becomes  the  touchstone  of 
the  diagnosis.  Now  it  may  be  asked.  Does  this  demonstrate  that  the 
diagnosis  of  a  case  is  not  necessary  for  its  treatment  ?  Xot  at  all.  It 
simply  proves  that  we  are  sometimes  obliged  to  aim  at  removing 
s}Tiiptoms  vithout  understanding  their  source.  But  it  does  not  prove 
that  if  we  understood  their  source  we  should  not  be  better  al^le  to 
remove  the  symptoms.  The  physician  who  undertakes  to  relieve 
disease  simply  by  attemptmg  to  allay  its  symptoms,  regardless  of  their 
cause,  and  without  understanding  their  true  relation  and  significance, 
is  groping  in  the  dark.  His  treatment  is  vacillating;  drug  replaces 
drug ;  aUe^dation  is  taken  for  a  cure  ;  and  the  experience  obtained  is 
utterly  untrustworthy.  One  great  advantage,  indeed,  of  attending 
carefully  to  diagnosis  is,  that  it  enables  us  to  use  remedies  knowingly 
and  with  decision ;  to  appreciate  what  they  are  effecting ;  to  abstain 
from  such  as  must  be  injurious.  There  is  less  needless  meddlmg, 
more  calmness:  the  treatment  rises  above  the  consideration  of -the 
moment,  and  takes  into  account  what  is  for  the  patient's  ultunate 
good.  But,  in  basing  the  management  of  a  disease  on  its  chagnosis, 
we  must  never  be  unmindful  how  important  it  is  to  found  that 
diagnosis  on  a  general  survey  of  all  the  circumstances  ;  how  neces- 
sary not  to  assign  prominence  to  muior  points  ;  and  how  the  extent 
of  the  affection,  the  circumstances  under  which  it  has  occurred,  the 
sympathetic  disturbances  .produced,  and  the  vital  state  of  the  patient, 
belong,  rightly  considered,  quite  as  much  to  the  diagnosis  as  the 
recognition  of  the  precise  seat  and  exact  anatomical  character  of  the 
malady,  and  are.  in  truth,  frequently  its  more  important  pari. 


CHAPTER     I. 

THE    EXAMINATION    OF    PATIENTS,    SYMPTOMS    OF    GENERAL   IMPORT, 
AND   SOME   OF   THE   INSTRUMENTS   EMPLOYED  IN   THE   DIAGNOSIS. 

To  elicit  the  facts  of  a  case  by  a  careful  examination  is,  as  has 
been  stated,  the  first  requisite  for  diagnosis.  To  conduct,  however^ 
a  clinical  inc|uiry  with  precision  and  facility,  requires  continual  prac- 
tice, and  is  rendered  easier  by  following  some  well-digested  plan. 
The  advantage  of  adopting  a  method  is  clearly  seen,  if  the  attempts 
of  a  beginner  be  watched.  He  wanders  in  his  search  from  one  part 
of  the  body  to  another,  attracted  by  different  symptoms  in  turn ; 
pointless  question  succeeds  to  pointless  question ;  and  a  conclusion, 
almost  certainly  erroneous,  is  finally  jumped  at,  or  an  acknowledgment 
made  of  inability  to  arrive  at  any. 

Now,  there  are  several  ways  which  have  been  proposed  to  over- 
come this  embarrassment.  One  of  the  principal  consists  in  first 
questioning  the  patient  with  regard  to  his  history.  His  ag-e  ;  his  occu- 
pation ;  the  diseases  from  his  childhood  up  ;  his  habits  ;  his  constitu- 
tion ;  the  affections  hereditary  in  his  family,  are  all  minutely  inquired 
into.  After  this  the  origin  and  progress  of  the  existing  disorder  are 
traced,  and  the  remedies  ascertained  that  have  been  used  against  it. 
The  present  condition  is  then  explored ;  each  organ  or  each  system 
being  in  turn  interrogated.  The  investigation  is  now  regarded  as 
complete  ;  the  facts  are  considered,  and  the  diagnosis,  prognosis,  and 
treatment  determined.  This  method  of  examining  is  termed  the  syn- 
thetical or  historical.  The  analytical  reverses  the  order.  The  present 
condition  is  first  ascertained^  and  subsequently  the  patient's  history 
or  anamnesis.  Both  of  these  courses  have  something  to  recommend 
them,  and  to  both  there  are  objections.  The  synthetical  method  is 
the  more  purely  scientific ;  but  it  is  too  full,  and  calls  for  too  much 
labor,  to  meet  the  requirements  of  ordinary  professional  life.  It  is 
much  better  adapted  for  recording  cases  in  the  pursuit  simply  of 
pathological  knowledge,  and  decidedly  the  best  where  the  history  is 
obscure  and  the  symptoms  are  ill  defined.  The  plan  which  I  habit- 
ually prefer  is  to  take  a  general  survey  of  the  history  and  of  the  promi- 
nent symptoms,  and,  having  thus  obtained  some  clue  to  the  part  most 
likely  to  be  affected,  to  explore  this  with  care.     For  instance  :  we  are 


26  MEDICAL  DIAGNOSIS. 

brought  to  the  bedside  of  a  patient  for  the  first  time  ;  we  inquire  how 
long  he  has  been  ill ;  how  that  illness  began  ;  in  what  way  he  is  now 
disturbed, — whether  he  has  pain,  or  what  is  the  main  source  of  his 
annoyance.  While  questioning  him,  we  are  scanning  his  appearance, 
the  position  of  the  body,  his  movements,  his  manner  of  breathing. 
The  hand  is  applied  to  the  skin ;  the  pulse  is  felt ;  the  tongue  is 
looked  at ;  the  temperature  is  taken.  Partly  from  this  examination 
and  partly  from  the  history,  some  organ  is  fixed  upon  to  be  specially 
investigated :  say  pain  in  the  epigastric  region  and  vomiting  are  com- 
plained of, — our  attention  is  directed  to  the  stomach.  We  explore 
this  organ,  its  physical  state  and  its  functions.  Then  we  look  to  the 
parts  that  are  anatomically  or  physiologically  most  nearly  related  to 
it,  which  are,  in  the  case  cited,  the  intestines  and  the  liver.  The 
examination  is  completed  by  taking  heed  of  the  condition  of  other 
portions  of  the  body ;  by  reviewing  the  history  of  the  case ;  and  by 
endeavoring  to  elicit  fully  such  points  as  bear  upon  the  diagnosis, 
which  the  mind,  consciously  or  unconsciously,  has  begun  to  frame. 
Then  a  balance  between  the  symptoms  is  struck,  the  diagnosis  is 
recast,  modified,  or  extended,  and  the  treatment  is  decided  upon. 

There  is  some  repetition  in  this  plan,  but  it  is  the  one  which  ap- 
pears practically  the  most  suitable.  It  has  the  advantage  of  bringing 
together  the  marked  features  of  a  case,  and  especially  those  most 
clearly  indicative  of  the  general  or  vital  condition.  But  whatever 
scheme  is  chosen,  it  should,  for  us  to  become  proficient  in  it,  be  as 
constantly  and  closely  adhered  to  as  the  varying  circumstances  of 
disease  will  permit.  Yet  to  acquire  thoroughly  the  habit  of  exam- 
ining with  accuracy  and  care,  and  also  to  obtain  the  full  fruits  of 
experience,  it  is  indispensable  to  keep  written  records.  This,  too, 
should,  so  far  as  possible,  be  done  according  to  a  uniform  design, 
since  it  both  prevents  us  from  overlooking  important  symptoms  and 
enables  cases  to  be  more  readily  compared.  I  subjoin  a  schedule 
that  is  based  on  the  plan  of  examination  just  mentioned. 

Date  of  examination ;  name  ;  age  ;  color ;  place  of  birth  ;  present 
abode ;  occupation  or  social  state ;  in  females,  whether  married  or 
not,  number  of  children,  and  date  of  last  confinement ;  hoAV  many 
miscarriages. 

History. 

1 .  History  antecedent  to  present  disease :  Constitution  and  gen- 
eral health — Hereditary  predisposition — Previous  dis- 
eases or  injuries  or  taints — Habits  and  mode  of  life ; 
hygienic  influences  to  which  exposed,  etc. 


EXAMINATION  OF   PATIENTS,  ETC.  27 

2.  History  of  present  disease :  Its  supposed  exciting  cause — 
Exposure  to  contagion — Date  of  seizure — Mode  of  inva- 
sion ;  subsequent  symptoms  in  order  of  succession — 
Previous  treatment. 

Present  Condition  of  Patient. 
Height  and  weight. 

1.  General  symptoms : 

p    ...      j  in  bed — mode  of  lying ; 

\  out  of  bed — movements  ;  gait  and  station ; 

Aspects     „  ' 

I,  01  countenance  ; 

Skin ; 

Pulse ; 

Temperature ; 

Respiration — as  to  frequency,  character,  etc. ; 

Tongue ; 

c  appetite ; 
General  state  of  digestion  <j  thirst ; 

I  condition  of  bowels  ; 
General  state  of  urinary  secretion  and  urinary  analysis  ; 
Sensations  of  patient :  pain,  etc. 

2.  Examination  of  special  regions^  parts,  and  functions,  begin- 

ning with  the  one  presumably  the  most  affected,  and 
embracing,  whenever  practicable,  microscopical  exami- 
nation of  the  blood  and  bacteriological  studies. 

Diagnosis. 

Treatment. 

Remarks. 

The  history  is  here  placed  first ;  then  the  symptoms  of  general 
import,  such  as  those  furnished  by  the  pulse,  the  tongue,  and  the 
temperature,  are  made  to  precede  the  examination  of  special  regions. 
These  general  symptoms  are  of  great  value  in  the  recognition  of  dis- 
ease, and  of  yet  greater  value  in  determining  its  treatment.  They  are 
more  than  the  mere  physical  signs  of  textural  affections ;  they  indi- 
cate vital  conditions,  and  partly  from  their  importance,  and  partly 
from  their  not  being  linked  to  disease  of  any  organ  in  particular,  they 
demand  a  separate  and  detailed  consideration. 

Position  of  the  Body. — By  noting  whether  the  patient  is  in  bed 
or  out  of  bed, — how  he  lies,  or  how  he  walks, — a  general  idea  may  be 
formed  as  to  the  acuteness  of  an  attack,  the  impairment  of  strengih 


28  MEDICAL  DIAGNOSIS. 

it  has  produced,  and  sometimes  even  as  to  its  nature.  Let  a  person 
who  has  been  actively  attending  to  his  usual  occupation  be  suddenly 
confined  to  his  bed,  and  the  inference  that  the  disease  is  an  acute  and 
a  severe  one  will  be  commonly  correct ;  certainly  so,  if  no  mishap  to 
the  organs  of  locomotion  have  necessitated  a  resort  to  the  recumbent 
position.  When  the  patient  lies  for  a  long  time  on  his  back,  it  is  gen- 
erally from  exhaustion,  or  from  paralysis,  or  it  is  owing  to  the  pain 
which  pressure  or  motion  of  any  kind  occasions.  Such  is  the  cause 
of  the  dorsal  decubitus  in  peritonitis,  and  in  rheumatism.  Lying 
steadily  on  the  back  mth  a  disposition  to  slip  down  in  bed  is  a  form 
of  dorsal  decubitus  witnessed  in  low  fevers.  Lying  fixedly  upon  one 
side  may,  as  a  rule,  be  looked  upon  as  an  indication  that  the  action 
of  the  lung  of  this  side  is  impeded,  and  that  the  respiration  has  to  be 
carried  on  with  the  other.  The  patient  may  be  confined  to  bed,  yet 
unable  to  lie  down  in  it,  on  account  of  the  distress  in  breathing  to 
which  the  recumbent  posture  gives  rise :  he  leans  forward,  or  sits 
erect.  This  necessity  of  breathing  in  the  upright  position,  or  "  or- 
thopnoea,"  is  a  form  of  dyspnoea  encountered  especially  in  diseases 
of  the  heart,  or  where  fluid  is  effused  into  the  air-cells  or  into  both 
pleural  cavities. 

If  a  person  is  able  to  be  about,  his  posture  and  movements  become 
important  manifestations  of  his  condition.  The  young  and  the  strong 
walk  erectly,  quickly,  and  firmly ;  the  aged  and  the  Aveak,  stoopingiy, 
slowly,  and  with  difficulty.  In  diseases  of  the  spine  the  body  is  bent ; 
so,  too,  in  affections  of  the  larger  joints  of  the  lower  extremities. 

When,  after  a  fever  or  any  other  prostrating  malady,  the  patient 
leaves  his  bed,  he  totters,  moves  slowly,  and  is  soon  obliged  to  rest : 
returning  strength  brings  with  it  a  quicker  and  steadier  gait.  In 
some  diseases  of  the  brain  the  movements  are  very  uncertain ;  in 
one-sided  palsy  the  affected  side  lags,  or  its  motions,  if  it  can  be  moved 
at  all,  are  laborious.  Excessive  and  uncontrollable  movements  are 
observed  in  mania  and  in  chorea ;  trembling  motions  in  states  of  ex- 
treme debility,  in  shaking  palsies,  and  in  the  defirium  of  drunkards ; 
irregular  motions  and  positions  chiefly  in  hysteria. 

The  gait  is  always  to  be  closely  studied.  We  find  it  of  special 
significance  in  affections  of  the  nervous  system  and  of  the  muscles. 
It  is  very  erratic,  from  side  to  side,  in  locomotor  ataxia,  and  there  is 
almost  total  inability  to  walk  in  the  dark.  In  paralysis  agitans  the 
tremors  are  associated  with  a  festinating  gait,  each  step  becoming 
more  rapid  than  the  last,  and  a  fall  is  only  averted  by  seeking  support. 
In  spastic  paraplegia  the  legs  drag  behind;  in  walking  each  leg  is 
rigidly  brought  forward,  the  toes    having   a  tendency  to  catch   the 


EXAMINATION  OF  PATIENTS,  ETC.  29 

ground.  In  pseudo-hypertrophic  paralysis  occurs  a  peculiar  oscillating 
or  waddling  gait,  from  weakness  of  the  extensors  of  the  knee  and 
hips  ;  there  is  also  much  difficulty  in  rising  from  the  ground.  In 
Thomsen's  disease  it  may  also  be  for  some  time  impossible  to  rise 
from  the  floor,  and  the  gait  is  at  first  impeded  by  tonic  spasm  of  the 
muscles. 

Station,  or  the  power  of  preserving  an  erect  position  while  stand- 
ing, is  often  as  characteristic  as  the  gait.  It  should  be  noted  while 
the  eyes  are  open,  while  they  are  shut,  and  while  the  feet  are  placed 
alongside  each  other  with  the  heels  and  toes  touching.  Under  both 
the  latter  circumstances  the  station  is  always  less  certain  and  the 
swaying  of  the  body  more  marked.  Tested  with  an  instrument 
invented  by  Weir  Mitchell,^  Hinsdale  ^  found  in  the  normal  man  and 
woman  the  average  sway,  while  the  heels  and  toes  were  touching,  to 
be  about  an  inch  in  the  forward  and  backward  line,  and  three-quar- 
ters of  an  inch  laterally.  Children  sway  to  a  greater  extent  than 
adults.  Closing  the  eyes  increases  the  sway  about  fifty  per  cent. 
In  locomotor  ataxia  station  is  much  disturbed  and  the  sway  greatly 
increased ;  so  it  is  in  disease  of  the  middle  lobe  of  the  cerebellum. 
In  the  attacks  of  aural  vertigo  all  power  of  standing  may  be  lost. 

General  Aspect — Expression  of  Countenance. — A  bulky 
aspect  of  the  whole  body  is  the  result  of  corpulency  or  of  universal 
anasarca;  In  the  exanthemata,  too,  a  general  tumefaction  may  take 
place.  A  partial  increase  or  a  swelling  arises  from  the  local  extrava- 
sation of  fluid  or  air  into  the  cellular  tissues.  If  air,  the  tissues 
crepitate  under  the  finger ;  if  fluid,  the  skin  pits  under  pressure.  A 
swelling  may  also  proceed  from  an  inflammatory  thickening  or  from 
a  tumor  or  any  morbid  growth. 

A  diminution  in  bulk  is  a  more  frequent  symptom  than  an  aug- 
mentation. It  may  occur  rapidly,  as  in  Asiatic  cholera.  More  gener- 
ally the  wasting  is  gradual,  and  is  an  indication  of  defective  nutrition. 
It  happens  in  the  course  of  protracted  fevers,  and  in  most  chronic 
diseases,  especially  in  those  attended  with  constant  discharges. 

Emaciation  is  most  readily  recognized  in  the  face.  But  it  is  not 
the  only  striking  alteration  observable  in  the  countenance  when  health 
has  failed.  There  may  be  pallor,  sallowness,  a  livid  hue  of  the  lips, 
a  puffy  appearance  of  the  eyelids,  a  flush  on  the  cheeks.  Now,  these 
changes  in  the  features,  added  to  the  expression  which  pain  or  special 
trains  of  thought  produce,  make  up  the  physiognomy  of  disease  so 
pregnant  with  meaning. 

1  Amer.  Journ.  Med.  Sci.,  1887.  =*  Ibid.,  April,  1887. 


30  MEDICAL  DIAGNOSIS. 

Among  the  countenances  most  frequently  met  with  is  that  of  apathy 
and  stupor.  The  eye  is  dull  and  listless  ;  the  face  pale  or  flushed. 
This  look  is  common  in  fevers  of  a  low  type,  and  is  often  combined 
with  blackish  accumulations  on  the  lips,  gums,  and  teeth. 

Unnatural  fulness  and  congestion  of  the  features  are  sometimes 
observed  in  enlargements  of  the  heart,  and  oftener  still  in  habitual 
drunkards.  The  same  aspect  is  seen  in  apoplexy  and  in  typhus  fever. 
Local  congestions  on  the  cheeks  and  nose  are  met  with  in  obstructive 
diseases  of  the  liver,  especially  in  cirrhosis,  and  in  the  endarteritis  of 
old  persons.  A  pinched  expression  is  found  when  there  is  intense 
anxiety  or  pain,  or  a  wasting  malady  attended  with  constant  suffer- 
ing. It  is  specially  observed  in  acute  peritoneal  inflammation.  When 
very  marked,  and  accompanied  by  change  of  hue,  it  is  the  face  which 
Hippocrates  has  so  graphically  described.  In  the  great  master's  own 
words,  "  a  sharp  nose,  hollow  eyes,  collapsed  temples  ;  the  ears  cold, 
contracted,  and  theii  lobes  turned  out ;  the  skin  about  the  forehead 
being  rough,  distended,  and  parched ;  the  color  of  the  whole  face 
being  green,  black,  livid,  or  lead-colored."  This  is  the  physiognomy 
of  approaching  death,  and  generally  its  speedy  forerunner,  except  in 
those  cases  in  which  the  expression  proceeds  from  want  of  food,  from 
protracted  vigils,  or  from  excessive  intestinal  discharges. 

The  face  of  shock,  with  its  great  pallor,  its  anxious  or  frightened 
look,  and  its  fixed  or  oscillating  eye,  often  with  a  contracting  pupil, 
is  a  face  seen  after  severe  injuries,  and  as  such  familiar  to  the  surgeon. 
But  in  many  of  its  main  traits  it  may  be  also  met  with  in  diseases 
that  make  a  sudden  and  overwhelming  impression  on  the  nervous 
system  ;  for  instance,  it  is  at  times  encountered  in  cerebro-spinal  fever 
and  in  cholera. 

Besides  these  lineaments,  which  may  be  said  to  be  common  to 
several  diseases,  we  read  frequently  in  the  countenance  the  signs  of 
special  disorders.  A  dusky  flush  on  the  face,  if  associated  with  rapid 
breathing,  is  almost  a  certain  indication  of  inflammation  of  the  lung. 
Puffiness  of  the  eyelids  in  a  pallid  person  is  most  apt  to  be  expressive 
of  Bright's  disease.  A  bluish  color  of  the  lips  shows  plainly  that  the 
venous  circulation  is  interfered  with,  or  that  the  blood  is  but  imper- 
fectly aerated.  The  cyanosis  is  also  recognized  in  the  blueness  of 
the  nails  and  the  duskiness  of  the  whole  surface.  Then  there  is 
the  chronic  pallor  of  the  anaemias  with  the  pearly  eye  and  the  yel- 
lowish tinge  of  the  pallor  in  chlorosis  ;  the  straw-colored  anasmic  hue 
of  malignant  disease ;  or  we  note  the  jaundiced,  melancholy  look  of 
an  hepatic  affection ;  the  downcast  expression  and  mobility  of  the 
features  in  hysteria ;  the  thickened  upper  lip,  delicate  skin,  and  fair 


EXAMINATION  OF  PATIENTS,  ETC.  31 

complexion  of  scrofula ;  the  sallow  countenance  and  peculiar  notched 
teeth  that  indicate  inherited  syphilis  ;  the  bronzed  skin  of  suprarenal 
disease ;  the  puffy,  vacant  face  of  myxoedema ;  and  the  various  traits 
which  tend  to  mark  not  only  the  special  diathesis,  but  also  the  peculiar 
temperament,  with  the  morbid  tendencies  that  belong  to  it. 

Skin. — By  the  state  of  the  skin  we  can,  to  a  great  extent,  judge  of 
the  activity  of  the  circulation  and  of  the  character  of  the  blood. 
Moreover,  it  is  a  fair  index  of  the  secretions,  and  of  the  condition  of 
the  system  at  large.  When,  after  pressure  on  the  skin,  the  blood  re- 
turns slowly  to  the  surface,  it  denotes  a  sluggish  capillary  circulation ; 
when  rapidly,  an  active  one.  Coldness  of  the  surface  indicates  a 
weakened  capillary  circulation,  and  is  met  with  at  the  invasion  of 
acute  diseases,  and  when  the  nervous  power  is  greatly  depressed.  If 
the  heat  of  surface  succeed  a  cold  skin,  we  know  that  reaction  has 
taken  place,  that  the  circulation  has  again  become  active.  Protracted 
coldness,  whether  attended  with  dryness  or  with  clamminess,  is  of 
evil  augury  ;  it  implies  seriously  diminished  vital  force. 

The  cutaneous  covering  is  pale  whenever  the  blood  is  poor  and 
watery.  Black  spots  may  be  seen,  due  to  extravasation.  Ofttimes 
the  surface  is  overspread  with  eruptions,  some  of  which  bear  a  close 
relation  to  disorders  of  internal  organs,  while  others  are  connected 
with  febrile  or  general  maladies  ;  and  others,  again,  are  owing  to  a 
disease  of  the  texture  itself. 

Tension  of  the  skin  is  met  with  in  acute  affections  accompanied 
by  active  excitement.  In  wasting  and  prostrating  ailments,  on  the 
other  hand,  the  skin  feels  very  relaxed  and  soft ;  and  in  those  pro- 
ducing rapid  emaciation,  it  is  inelastic  and  lies  in  folds. 

Pulse. — The  pulse  enlightens  us  on  the  action  of  the  heart,  and 
on  the  state  of  the  artery  itself  and  of  the  blood.  In  a  healthy  adult 
a  beat  of  some  resistance  is  felt,  recurring  from  sixty-five  to  seventy- 
five  times  in  a  minute.  It  becomes  slower  with  advancing  years, 
though  it  may  rise  in  the  very  aged.  The  pulse  of  infancy  is  from 
one  hundred  and  ten  to  one  hundred  and  twenty ;  that  of  a  child 
three  years  old,  from  ninety  to  ninety-five.  Warmth  quickens  the 
pulse ;  so  do  rapid  breathing,  forced  expiration,  and  the  process  of 
digestion.  In  the  recumbent  position  and  during  sleep  it  falls.  For 
purposes  of  comparison,  the  pulse 'should  be,  so  far  as  possible,  taken 
under  similar  conditions. 

At  the  bedside  we  study  in  the  pulse  its  frequency,  its  rhythm,  its 
volume  and  strength,  and  its  resistance. 

Increased  frequency  of  the  pulse  denotes  increased  frequency  of 
the  heart's  action,  and  arises  from  any  cause  that  excites  the  heart. 


32  MEDICAL  DIAGNOSIS. 

Hence  exercise,  rapid  breathing,  mental  emotion,  or  restlessness  will 
occasion  the  number  of  beats  to  exceed  the  average  of  health  as 
readily  as  fevers  or  acute  inflammatory  diseases.  In  great  debility, 
too,  the  pulse  rises  ;  and  the  more  depressed  the  vital  condition,  the 
higher  the  pulse  becomes.  In  exophthalmic  goitre  the  pulse  is  gen- 
erally very  frequent,  and  rapid  heart  action  may  show  itself  without 
any  other  obviously  abnormal  state,  as  in  tachycardia,  a  disorder  in 
which  the  pulse  may  considerably  exceed  two  hundred  beats  in  the 
minute.  Under  the  influence  of  suggestion  the  cardiac  action  may  be 
made  very  much  more  rapid  or  slower.^  As  a  sequel  of  influenza 
there  is  often  very  rapid  heart  action.  The  heart  may  thus  quicken 
from  so  many  and  such  varied  causes,  acting  temporarily  or  per- 
manently, that  increased  frequency  of  pulse,  taken  by  itself,  has  no 
significant  diagnostic  meaning. 

A  slow  pulse,  too,  happens  in  many  different  states, — in  cold,  in 
exposure  to  wet,  in  icterus,  in  protracted  convalescence  from  acute 
disease.  It  is  also  produced  by  an  intense  and  prostrating  shock,  or 
is  found  coexisting  with  pressure  on  the  brain,  with  melancholia,  with 
atheroma,  with  fatty  heart.  A  permanently  slow  pulse  is  also  met 
with  in  irritative  lesions  of  the  cerebral  centres,  among  them  in 
spherical  or  pediculated  thrombi,  in  altered  state  of  the  circulation 
in  the  medulla,  and  in  injuries  to  the  pneumogastric.  It  is  not 
unusual  in  instances  of  very  slow  pulse,  or  brachycardia,  to  observe 
two  or  three  abortive  beats  succeeding  a  strong  beat.  In  some 
persons  the  pulse  is  naturally  very  slow. 

The  rhythm  of  the  pulse  is  often  perverted.  Instead  of  the  beats 
following  one  another  in  regular  succession,  they  are  unequal,  or  one 
or  two  intermit.  An  irregular  pulse  occurs  from  digestive  disorder, 
from  gout,  from  lithaemia,  from  the  excessive  use  of  tobacco,  tea  or 
coffee,  or  from  nervous  exhaustion  ;  it  is  less  frequently  the  indication 
of  a  cerebral  or  cardiac  lesion.  It  is  sometimes  a  difficult  beat  to 
count ;  and  we  must  be  careful  not  to  regard  at  once  a  pulse  as  irreg- 
ular because  it  appears  to  intermit.  The  seeming  irregularity  may  be 
caused  by  the  fingers  slipping  from  the  artery,  which  they  are  very  apt 
to  do  after  they  have  been  on  the  vessel  for  some  time. 

Where  every  other  beat  is  uneven  in  size,  thus  showing  a  beat  of 
greater,  followed  regularly  by  one  of  lesser,  altitude,  though  the 
rhythm  may  be  regular,  we  have  the  pulsus  alternans.  Where  a  beat 
is  dropped, — in  other  words,  where  the  heart-beat  is  not  transmitted 
to  the  artery  with  sufficient  force  to  be  felt, — it  is  designated  as  an 

^  Sgobbo-Nuovo  Rivista,  1,  1892. 


EXAMINATION   OF  PATIENTS,  ETC.  33 

abortive  beat.  Two  imperfect  or  abortive  beats  occurring  in  rapid 
succession,  and  followed  by  a  long  pause  and  generally  by  a  distinct 
beat,  form  a  linked  beat. 

The  volume  and  strength  of  the  pulse  are  of  much  more  importance 
than  either  its  rhythm  or  its  frequency.  Volume  and  strength  are 
often  associated,  and  are  much  alike ;  but  they  are  not  identical. 
When  the  beat  of  the  artery  is  large,  we  call  it  3i.full  pulse.  This  is 
owing  to  the  distention  of  the  vessel  with  blood, — its  complete  expan- 
sion with  every  beat  of  the  heart.  A  full  pulse  is,  therefore,  the  pulse 
of  plethora ;  the  pulse  of  the  young  and  robust  in  health,  or  in  in- 
flammatory diseases  ;  the  pulse  in  the  early  stag-es  of  fevers,  or  in 
obstruction  of  the  capillaries.  It  is  usually  a  pulse  of  power,  just  as 
its  opposite,  a  small  pulse,  is  usually  the  pulse  of  debility.  Yet  a  full 
pulse  may  be  produced  by  the  distention  of  an  artery  which  has  lost 
its  tone,  and  which  the  fmger  easily  compresses.  Such  a  pulse,  the 
"  gaseous  pulse,"  a  pulse  really  of  low  tension,  denotes  exhaustion, 
and  proves  that  a  full  pulse  and  a  strong  pulse  are  not  always  synon- 
ymous. Into  the  idea  of  strength  something  more  than  mere  fulness 
enters.  A  strong  pulse  is  a  pulse  heightened  in  all  its  natural  charac- 
ters. It  has  more  fulness,  but,  in  addition,  more  impulse,  and  less 
compressibility,  than  an  ordinary  pulse.  A  strong  pulse,  therefore,, 
indicates  activity  of  the  contraction  of  the  heart,  and  a  normal,  per- 
haps increased,  tonicity  of  the  arterial  coats.  It  is  found  in  active 
inflammations  ;  also  in  hypertrophy  of  the  heart.  Its  opposite,  a 
weak  pulse,  betokens  want  of  force,  often  want  of  healthy  blood.  It 
is  generally  small  as  well  as  weak.  Yet  as  the  full  pulse  is  not  always- 
strong,  neither  is  the  small  pulse  always  weak.  The  small  choked 
pulse  of  peritoneal  inflammation  may  be  fine  and  wiry,  but  it  is  not 
a  weak  pulse.  We  also  find  a  small  pulse  of  high  tension  in  mitral 
stenosis  and  in  contracted  kidney. 

The  resistance  or  tension  of  the  pulse  is  another  valuable  guide. 
A  hard,  tense  pulse  denotes  increased  contractility  of  the  arteries, 
and  generally  high-wrought  power.  It  tells  us  that  the  blood  is  being 
driven  with  force  along  the  arterial  system.  But  it  also  tells  us  that 
the  irritation  has  implicated  the  coats  of  the  arteries  themselves,  or 
that  there  is  obstruction  in  the  capillaries.  A  tense  pulse  is  met  with 
in  active,  violent  inflammations,  and  sometimes,  though  not  often,  in 
states  of  extreme  and  continued  excitement  without  inflammation. 
It  is  almost  needless  to  add  that  changes  in  the  coats  of  the  arteries 
may  also  be  a  cause  of  a  hard  and  resistant  beat,  the  common  cause 
of  the  increased  tension  in  elderly  people.  Where  no  local  altera- 
tions are  present,  and  where  no  acute  symptoms  explain  the  syni- 

3 


34  MEDICAL  DIAGNOSIS. 

pathetic  disturbance  of  the  heart  and  arterial  system,  the  high  arterial 
tension  will  be  commonly  found  associated  mth  hypertrophy  of  the 
left  ventricle,  mth  mterstitial  nephritis,  with  disease  of  the  suprarenal 
capsule,  with  gout  or  lithgemia,  or  with  septicaemia. 

The  opposite  of  the  hard  pulse  is  the  soft  or  compressible  pulse. 
This  miplies  deficient  impulsion,  and  loss  of  tone  in  the  vessel ;  it  is 
the  pulse  of  low  fevers,  of  debility,  of  cardiac  weakness.  But  it  is 
also,  when  followmg  a  tense  state  of  the  artery,  the  pulse  which  de- 
notes returning  health,  and  danger  passed. 

When  the  pulse  is  of  low  tension,  and  at  the  same  time  frequent, 
it  may  show  double  beats  with  each  contraction  of  the  heart.  This 
dicrotic  pulse  is  most  often  met  with  in  fevers  of  a  low  form  and  pre- 
ceding or  during  the  continuance  of  hemorrhages.  The  rebound  is 
chiefly  due  to  the  oscillation  of  the  column  of  blood  m  the  arteries, 
and  is  very  much  influenced  by  their  elasticity.  With  lowered  tension 
and  increased  elasticity  of  the  tubes,  dicrotism  becomes  obvious, 
especially  with  a  rapid  circulation.  In  old  persons,  in  whom  the 
coats  of  the  arteries  are  melastic,  dicrotism  is  but  feebly  marked. 

Such  are  the  meanings  attached  to  the  various  characters  of  the 
pulse.  Yet  they  do  not  often  present  themselves  thus  isolated.  The 
following  are  usually  combined,  and  bear  this  explanation : 

A  hard,  full,  frequent  impulse  occurs  in  active  inflammations,  and 
in  most  of  the  acute  diseases  of  robust  persons. 

A  hard  pulse,  full  or  small,  bounding  or  not,  if  unconnected  with 
acute  symptoms,  leads  to  the  suspicion  of  cardiac  or  of  renal  disease, 
or  of  an  affection  of  the  artery  itself. 

A  tense,  contracted,  and  frequent  pulse  is  met  mth  in  a  large 
group  of  inflammations  below  the  diaphragm,  as  m  enteritis,  peri- 
tonitis, gastritis. 

A  frequent  pulse,  full  or  smaU,  but  not  tense,  is  the  pulse  of  most 
idiopathic  fevers,  and  with  marked  low  tension  is  also  apt  to  be 
dicrotic. 

A  very  frequent  pulse,  but  very  feeble  and  compressible,  is  the 
pulse  of  marked  debility,  of  prostration,  of  collapse. 

A  pulse  frequent,  and  changeable  in  its  rhythm,  is  produced,  for 
the  most  part,  by  perverted  innervation  in  connection  with  gastric 
disorders,  by  tobacco,  by  neurasthenia,  or  by  disease  either  of  the 
heart  or  of  the  brain.     ■ 

To  recognize  readily  fine  shades  of  difference  and  to  record  the 
movements  of  the  pulse,  instruments  have  been  sought.  The  best  of 
these  is  the  sphygmograph  invented  by  Marey  (Fig.  1).  Slight  irregu- 
larities that  wholly  escape  the  finger  are,  through  its  aid,  discerned 


EXAMINATION   OF  PATIENTS,  ETC. 


35 


with  facility,  and  we  know  at  once  in  how  far  these  irregularities 
belong  to  one  beat  or  to  a  succession  of  beats.  Double  beats,  too, 
not  appreciable  to  the  hand,  are  easily  detected.  Indeed,  the  sphyg- 
mograph  proves  the  phenomenon  of  dicrotism  to  exist  in  almost 
every  person.  The  rebound  may  occur  during  the  systole  or  the 
diastole  of  the  vessel ;  and  instead  of  one,  there  may  be  four  or  five 
of  the  secondary  pulsations. 

Fig.  1. 


Marey's  sphygmograph  attached  to  the  wrist.    Its  tracings  are  shown  by  the  wtiite  lines  on  the  black 

background. 

The  mode  of  adjusting  the  instrument,  and  of  proportioning  the 
pressure  of  the  spring,  has  something  to  do  with  the  kind  of  delinea- 
tion obtained ;  and  to  secure  greater  accuracy,  a  number  of  modifica- 
tions have  been  made,  chiefly  with  the  view  of  registering  the  amount 
of  pressure.     The  sphygmograph  of  Dudgeon  (Fig.  2)  is  simple  and 

Fig.  2. 


Dudgeon's  sphjgmograph. 


much  employed.     The  system  of  levers  is  the  same  as  in  Marey's, 
but  the  slip  of  paper  moves  in  a  different  direction. 

To  show  the  tracing  distinctly,  smoked  glass  or  mica,  or  paper 
smoked  over  a  lamp  or  by  burning  camphor,  is  much  used ;  and  the 


36 


MEDICAL  DIAGNOSIS. 


Fig.  3. 


tracing  may  be  preserved  by  dipping  it  in  an  alcoholic  solution  of 
shellac  or  of  benzoin,  or  of  a  varnish  of  benzoin  and  methylated 
spirit,  in  the  proportion  of  one  to  six.  On  every  tracing  the  amomit 
of  pressure  employed  should  be  noted.  Manifold  have  been  the  sug- 
gestions to  obtain  the  steadiest  application  of  the  instrument  to  the 
forearm  and  the  greatest  development  of  the  tracing.  Lorain  ^  has 
proved  that  raising  the  arm  to  a  vertical  position  gives  a  much  more 
ample  trace  ;  and  Richardson  ^  shows  that  with  the  body  in  the  hori- 
zontal line,  the  dicrotic  wave  becomes  more  prominent. 

When  we  apply  the  sphygmograph  for  clinical  purposes,  we  study 
in  its  tracing  the  line  of  ascent,  the  summit,  and  the  line  of  descent. 

Each  pulsation  is  composed  of  these 
three  parts.  The  line  of  ascent,  the 
upstroke,  tells  us  the  manner  in  which 
the  blood  enters  the  vessels.  The 
more  rapid  the  flow,  and  the  more 
quickly  the  artery  distends,  the  more 
strictly  vertical  the  line.  The  force, 
too,  is  indicated  by  this  line,  or  rather 
by  its  height :  hence  when  the  muscles 
of  the  heart  contract  powerfully,  either 
from  enlargement  or  from  overaction, 
the  line  is  both  vertical  and  high.  Yet 
the  strength  of  the  ventricular  contrac- 
tion is  far  from  being  the  only  cause  in- 
fluencing the  amplitude  of  the  tracing.  Indeed,  as  we  may  note  in 
old  persons,  a  large  volume  of  the  artery  gives  considerable  height  to 
the  lines  of  ascent ;  so  does  a  long  interval  between  the  pulsations, 
or  the  obstruction  of  the  vessel  below  the  point  where  the  obser- 
vation is  made.  Low  tension  in  the  arteries  or  m  the  capillaries  has 
the  same  eifect ;  whereas  when  the  passage  in  the  ultimate  ramifi- 
cation of  the  vascular  system  is  difficult,  the  lever  descends  slowly 
by  a  convex  line,  and  is  soon  again  raised  by  the  next  pulsation. 
When  the  contraction  of  the  heart  is  feeble,  the  line  of  ascent  is  not 
vertical  or  high,  but  oblique  and  short.  In  aneurisms  of  the  thoracic 
aorta — indeed,  in  an  aneurism  interposing  anywhere  between  the 
heart  and  the  radial  artery — an  oblique  and  short  upstroke  is  also 
met  with. 

The   line  joining   the    summit  of  a   series  of  pulsations,   or  the 
maxuna  of  tension,  is  generally  a  straight  line  ;  a  similar  imaginary 


Sphygmogbam  enlarged.— a,  b,  up- 
stroke, or  line  of  ascent ;  a,  6,  c,  percus- 
sion-wave ;  c,  d,  e,  tidal,  or  predicrotic 
wave ;  d,  e,f,  aortic  notch ;  e,  /,  g,  dicrotic 
wave ;  /,  g,  diastolic  period. 


1  The  Asclepiad,  1886. 


2  Le  Pouls,  Paris,  1870. 


EXAMINATION   OF  PATIENTS,  ETC.       »  37 

line  connecting  the  bases,  or  the  minima,  is  apt  to  run  parallel  to  it ; 
but  irregularity  of  pulsation  leads  to  irregular  lines,  and  the  lower 
line  may  be  irregular  while  the  upper  is  straight.  Irregularity  of  the 
base  line  is  seen  in  marked  dyspnoea. 

The  summit  of  the  pulsation  informs  us  of  the  time  during  which 
the  entrance  of  blood  balances  the  onward  flow.  A  pointed,  distinct 
summit-wave  belongs  to  vigorous  contraction  of  the  heart-muscle. 
The  summit  may  be  a  horizontal  line  of  some  length.  This  broaden- 
ing of  the  apex  happens  in  high  and  prolonged  arterial  tension,  such 
as  from  the  slow  contraction  of  a  strong  heart,  fulness  of  the  vessels, 
or  obstruction  in  the  capillaries ;  an  extended  plateau  is  also  met 
with  in  induration  or  ossification  of  the  arteries. 

In  some  instances  we  fmd  a  little  hooked  point  preceding  the 
usually  transverse  mark  of  the  summit.  This  occurs  by  the  rapid 
'movement  of  the  lever,  and  is  generally  a  sign  of  regurgitation  co- 
existing with  obstruction  at  the  aortic  valves.  In  aortic  narrowing 
of  marked  degree  the  summit-wave  is  indistinct  or  absent ;  the 
line  of  ascent  is  oblique  and  gradual,  and  may  show  a  break  near 
the  summit. 

The  line  of  descent  is  sometimes  purely  oblique,  and  the  more  rap- 
idly the  pressure  is  lessened  in  the  arterial  system,  the  more  oblique 
is  the  line.  It  often  shows  a  series  of  undulations.  The  first  of 
these  waves  is  called  the  tidal  wave ;  it  is  still  part  of  the  systole  and 
onward  flow  of  the  blood ;  the  decided  subsequent  wave  is  specially 
called  the  dicrotic  or  great  secondary  wave.  The  closure  of  the 
aortic  valves  with  the  second  sound  of  the  heart  happens  just  before 
the  dicrotic  wave  ;  the  exact  time  is  marked  by  the  aortic  notch ;  the 
dicrotic  wave  represents  the  diastole  of  the  heart.  The  tidal  wave 
is  large,  but  the  dicrotism  badly  marked,  in  atheroma.  In  high  ar- 
terial tension  the  dicrotic  wave  is  also  ill  pronounced,  and  the  line  of 
descent  is  very  gradual.  In  mitral  narrowing,  the  line  of  descent  is 
long,  but  is  broken  by  small  pulsations. 

The  sphygmograph  requires  care  and  practice  in  its  use,  and,  on 
the  whole,  it  is  of  much  more  avail  in  investigations  on  the  exact 
action  of  medicines — where,  indeed,  it  is  of  great  value — than  in 
aiding  us  materially  in  questions  of  diagnosis  or  in  decisions  on  treat- 
ment. At  all  events,  I  do  not  think  that  it  supersedes  the  older  and 
more  usual  means  of  research.  Perhaps  records  of  pulse-traces  in 
which  the  amount  of  pressure  has  been  carefully  noted  will  enable 
us  to  judge  more  accurately  than  we  can  now  of  the  state  of  the 
cardiac  muscles  in  disease. 

An  instrument  aiming  at  even  greater  accuracy  than  the  ordinary 


38  ,  MEDICAL  DIAGNOSIS. 

sphygmograph  is  the  sphygmochronograph}  It  is  similar  in  its  con- 
struction to  tlie  sphygmograph  of  Dudgeon,  but  it  enables  us  to 
measure  the  curves  of  the  tracings,  and  to  ascertain  the  exact  time  of 
each  part. 

Normally  capillaries  do  not  pulsate.  We  judge  of  their  dilatation 
by  the  flush,  of  their  contraction  by  pallor.  But  in  certain  patho- 
logical conditions  they  beat,  as  may  be  observed  in  the  capillary  flush. 
We  may  note  the  capillary  pulsation  in  instances  of  chlorosis  and  of 
aortic  regurgitation.  The  capUlary  flush  has  generally  to  be  brought 
about  artificially  by  pressure  on  the  skin,  the  naUs,  or  the  lips.  We 
can  then  perceive  the  pink  changing  in  color  vdth  each  pulsation,  or 
disappearing  after  it.  The  most  marked  changes  are  observable  at 
the  periphery  of  the  pink  patch.  In  those  rare  instances  in  which 
the  capillary  pulse  is  regurgitant  and  of  venous  origin,  as  in  tricuspid 
regurgitation,  we  find  venous  pulsation  everywhere,  and  the  capillary 
pulsation  precedes  the  radial  heat. 

Temperature  of  the  Body. — The  thermometry  of  disease  is 
indispensable.  The  thermometer  used  for  clinical  purposes  should  be 
very  sensitive,  and  requires  to  be  from  tmie  to  time  compared  with  a 
standard  one,  and  verified ;  it  should  be  self-registermg.  The  detached 
part,  or  the  index,  is  set  by  bringing  it  down  below  the  lines  of  the  scale 
by  a  rapid  swing  of  the  arm ;  a  mag-nifymg  front  allows  the  degrees  to 
be  easily  read.  Very  dehcate  but  fragile  thermometers,  registering  in 
a  mmute  or  less,  have  of  late  come  into  use.  Metallic  thermometers 
are  neither  so  cleanly  nor  so  trustworthy  as  those  made  of  glass. 

As  surface  thermometers  for  localized  thermometry  various  instru- 
ments have  been  suggested.  I  habitually  employ  one  wliich  has  the 
mercury  m  a  fine  coil  at  the  expanded  extremity,  and  wliich  is  self- 
registering.  We  should  first  obtain  the  heat  of  a  corresponding  well 
part,  and  then  leave  the  bulb  for  five  mmutes  on  the  suspected  abnor- 
mal structure.  Better  still  is  it  to  apply  two  mstruments  at  the  same 
time  ;  one  on  the  sound,  the  other  on  the  unsound  side.  In  all  obser- 
vations the  heat  of  the  body,  as  ascertained  in  the  axilla,  should 
equally  be  noted. 

The  surface  temperature  is,  as  a  rule,  lower  by  upward  of  one  or 
by  several  degrees  than  the  general  temperature.  We  find  it  so  on  the 
chest,  on  the  abdomen,  and  on  the  head.  The  temperature,  too,  is 
not  on  corresponding  sides  entirely  the  same,  at  least  not  on  the  head. 
There  is  almost  always  a  slight  inequality  in  the  temperature  of  the 


^  Jaquet,  Zeitschrift  fiir  Biologie,  1891  ;  and  Muhll,  Deutsch.  Arch.  f.  klin.  Med. 
1892,  xlix. 


EXAMINATION   OF  PATIENTS,  ETC. 


89 


Fig.  4. 


11= 


Ij 


Self-Registering  Thei- 
mometer,  showing  the 
index  marking  99°  F. 
shortly  after  an  obser- 
vation. 


Seguin's  Surface 
Thermometer, 
modified  to  be 
self  -  register- 
ing. 


Surface  Thermometer,  with  coil  at  ex- 
tremity. It  may  be,  if  necessary, 
kept  in  place  by  a  thin  elastic  band. 


40  MEDICAL  DIAGNOSIS. 

two  sides  of  the  head;  Gray^  demonstrates  that  when  at  rest  the 
temperature  of  the  left  hemisphere  is  the  higher,  which  accords  with 
Broca's  statement.  And  the  observations  of  Amidon^  have  shown 
that  excessive  use  of  a  group  of  muscles  may  generate  heat,  in  the 
cortical  centres  presiding  over  them,  sufficient  to  manifest  itself  to 
surface  thermometers  placed  on  the  scalp  ;  emotional  and  intellectual 
activity  Lombard  has  proved  will  do  the  same.  The  mean  tempera- 
ture of  a  healthy  man's  head  is  fixed  by  Maragliano  and  Seppili,  as 
the  result  of  many  observations,  at  36.13°  C.  (97.03°  F.)  for  the  left 
side  of  the  head,  and  36.08°  C.  (96.9°  F.)  for  the  right.^  These  tem- 
peratures are  higher  than  those  given  by  Broca  and  Gray.  Broca 
places  the  frontal  region  on  the  left  side  of  the  head  at  35.43°  C. 
(95.79°  F.),  on  the  right  at  35.22°  C.  (95.39°  F.).  The  parietal  region 
on  the  right  side  is  fixed  by  Broca  at  92.8°  ;  by  Gray  at  93.6°  on  the 
right,  and  94.4°  on  the  left ;  the  vertical  by  Gray  at  91.7°,  and  the 
occipital  at  91.9°  ;  the  whole  side  of  the  head  by  Broca  at  about  93°  ; 
the  entire  head  at  places  remote  from  these  points  at  93.5°  by  Gray.* 
In  furious  mania  a  temperature  of  36.9°  C.  has  been  observed,  and 
a  rise  of  temperature  has  also  been  noted  over  brain  tumors,  cere- 
bral abscesses,  and  tubercular  mflammation.^  But,  on  the  whole, 
cerebral  thermometry  has  not  proved  itself  of  much  value. 

As  regards  the  abdomen,  Peter  ^  places  the  normal  mean  of  the 
parietes  at  35.5°  C.  (95.9°  F.),  and  the  same  observer  records  the 
normal  temperature  for  the  chest-walls  at  about  36°  C.  (96.8°  F.). 
Certain  diseases  change  the  temperature  locally.  Thus,  m  neuralgia 
the  heat  near  the  painful  points  may  be  markedly  raised.  So,  too, 
is  it  sometimes  in  some  parts  of  the  surface  in  hysterical  women. 
In  hemiplegia  the  paralyzed  limb  may  show  a  higher  temperature 
than  the  sound  one ;  and  over  spots  where  there  is  inflammation 
or  where  decided  tissue-change  is  going  on  there  is  a  rise  in  local 
temperature.  Weir  Mitchell^  has  cafied  attention  to  the  manner 
in  which  posture  affects  surface  temperature.  It  is,  for  instance,  less 
by  0.4°  C.  to  1°  C.  on  the  dorsum  or  sole  of  the  foot  when  standing 
than  when  lying  down. 

But  to  return  to  general  thermometry.     The  clmical  thermometer 

1  Chicago  Journal  of  Mental  and  Nervous  Diseases,  1879. 
^  New  York  Archives  of  Medicine,  April,  1880. 
^  Translated  in  Alienist. and  Neurologist,  St.  Louis,  Jan.  1880. 
^  New  York  Archives  of  Medicine,  1879,  vol.  ii. 

5  Eskridge,  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1883. 
^  Communication  to  the  Academie  de  Medecine,  quoted  in  Medical  Times  and 
Gazette,  Dec.  1879. 

'  Medical  News,  Jan.  1894. 


EXAMINATION   OF  PATIENTS,  ETC. 


41 


may  be  put  under  the  tongue  or  in  the  rectum  ;  but  the  most  suitable 
site  in  adults  is  the  axilla.  The  bulb  is  pressed  into  the  armpit  and 
kept  in  close  contact  with  the  skin  for  five  minutes,  except  when  the 
delicate  minute  thermometers  are  employed.  The  thermometer  may 
be  conveniently  introduced  just  below  the  skin  covering  the  edge  of  the 
pectoralis  major  muscle  ;  and,  to  insure  exactness,  the  axilla  should  be 
kept  well  covered.  In  using  the  thermometer  in  the  mouth  we  must 
be  careful  that  it  be  not  used  soon  after  anything  hot  or  cold  has  been 
taken.  The  effect  of  heat  in  the  mouth  is  more  prolonged  than  of  cold.^ 
In  all  cases  of  importance,  not  less  than  two  observations  should 
be  made  daily,  and,  so  far  as  possflDle,  every  day  at  the  same  hour. 
Between  seven  and  nine  o'clock  in  the  morning,  and  about  seven 
o'clock,  or  somewhat  earlier,  in  the  evening,  are  regarded  as  the  most 


Fig.  7. 


Name 


Disease . 


Day  or 
Month 

Day  of 
Di.sease       ^    ^ 

3    4-5678 

9   10  U  12  13  14  ] 

5  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35 

SlE  ME 

ME  ME  ME  HE  ME  ME 

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Temperature  chart  in  simple  continued  fever.  The  initial  stage,  the  stage  in  which  tlie  tempera- 
ture rises  to  its  height,  is  here  attained  on  the  second  day ;  the  fastigium,  the  stage  at  which  it  remains, 
with  sliglit  fluctuations,  at  its  height,  lasts  until  the  sixth  day  ;  the  defervescence,  the  stage  when  the 
fever-heat  falls,  is  rapid,  by  crisis,  and  a  subnormal  point  is,  for  a  time  attained. 

appropriate  periods.  If  only  a  single  observation  be  taken,  it  is  best 
done  in  the  late  afternoon  or  in  the  evening.  In  every  record  of  the 
temperature  the  pulse  and  the  respirations  must  also  be  noted.  For 
the  purpose  of  record  clinical  charts  should  be  always  used.     Fig.  7 


Lazarus-Barlow,  Lancet,  Oct.  1895. 


42 


MEDICAL  DIAGNOSIS. 


is  a  simple  model.  It  can  be  arranged  for  thirty  days  or  upward  ;  by 
striking  out  the  morning  and  evening  marks,  as  many  spaces  as  needed 
can  be  devoted  to  a  case  ;  or  by  using  a  marking  in  red  ink  in  addition 
to  the  black  line  in  which  the  morning  and  evening  temperature  is  re- 
corded, as  near  as  may  be  always  at  the  same  hour,  the  supplementary 
temperature  can  easily  be  traced  (Fig.  8).     Where  w^e  wish  also  to 

Fig.  8. 


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16 

Temperature  chart,  from  a  case  of  remittent  fever  in  a  sailor  at  the  Pennsylvania  Hospital  (No.  1570). 
The  red  lines  show  the  intermediary  temperatures. 

show  the  pulse  and  the  respiration  graphically,  the  chart  of  Crozer 
Griffith  is  excellent.  In  discussing  pneumonia,  farther  on,  one  of 
these  charts  is  shown. 

In  temperate  climates  the  average  heat  of  the  body,  as  measured 
in  the  axiha,  is  estimated  at  37°  C.  (98.6°  F.) ;  ^  that  of  freshly  voided 


^  It  may  be  useful,  for  the  sake  of  comparison,  to  recall  the  fact  that  one  degree 
of  Fahrenheit  is  equal  to  five-ninths  of  a  degree  of  the  Centigrade  thermometer, 
and  four-ninths  of  a  degree  of  Reaumur ;  and  also  that  the  freezing-point  of  the 


EXAMINATION  OF  PATIENTS,  ETC.  43 

urine  is  about  the  same.  This,  at  least,  is  the  case  in  the  axilla ;  in 
the  rectum  it  is  not  quite  one  degree  higher,  and  is  very  steady ;  in 
the  mouth  it  is  somewhat  lower.  In  the  groin,  where,  in  children,  it 
may  be  most  convenient  to  take  it,  the  temperature  is  apt  to  be  lower 
than  in  the  axilla. 

The  body  temperature  rises  with  the  temperature  of  the  air,  and 
fluctuates  slightly  during  the  day,  being  in  temperate  climates,  accord- 
ing to  the  most  trustworthy  observers,  lowest  between  two  and  eight 
in  the  morning,  and  highest  late  in  the  afternoon.  It  is  heightened 
by  exercise  and  reduced  by  sustained  mental  exertion,  and  changes 
even  when  we  are  at  rest.  But,  as  a  rule,  with  the  exception  of  very 
active  exercise,  no  cause  save  disease  induces  a  variation  of  much 
more  than  one  degree ;  even  in  the  extreme  heat  of  tropical  climates 
the  animal  heat  does  not  surpass  99.5°.  Thus  a  temperature  above 
this,  or  more  than  a  degree  below  the  average  stated,  when  persist- 
ent, indicates  some  morbid  action  in  the  economy.  At  all  events,  it 
does  so  in  adults  ;  in  very  aged  persons  a  temperature  of  97°  may 
still  be  normal ;  while,  on  the  other  hand,  the  range  may  be  as  high 
as  in  infants. 

In  children,  in  whom  the  temperature,  as  a  rule,  is  somewhat 
higher  than  in  adults,  the  daily  range  is  much  greater.  It  falls  rapidly 
in  the  evening,  and  is  very  much  influenced  by  food  and  by  crying. 
In  the  new-born"  it  is  about  99.8°  to  100.4°  in  the  rectum.  It  falls 
from  early  infancy  to  puberty.  The  rectal  temperature  of  young 
children  ranges  between  99°  and  99.7°  ;  under  six  years  of  age  the 
mean  is  99.4°.  The  maximum  is  attained  in  the  afternoon.  During 
the  first  three  or  four  months  of  life  the  temperature,  Henoch  asserts, 
has,  from  slight  causes  of  faulty  nutrition,  a  marked  tendency  to  go 
below  the  normal.  A  further  point,  too,  to  be  taken  into  account  in 
those  of  all  ages  is,  that  the  temperature  is  somewhat  influenced  by 
food  and  stimulants  and  by  prolonged  application  of  the  thermome- 
ter. And  these  are  the  elements  which  make  deductions  from  single 
observations  or  comparatively  slight  changes  untrustworthy.  In  high 
altitudes,  as  Keating '^  has  observed,  there  is  a  tendency  to  hyper- 
pyrexia. 

In  ordinary  cases  the  pulse  and  temperature  rise  synchronously, 


first  is  placed  at  32°  ;  that  of  the  others  at  zero.  To  convert  Centigrade  into 
Fahrenheit,  we  multiply  by  9  and  divide  by  5  ;  to  convert  Reaumur,  w^e  multiply 
by  9  and  divide  by  4 ;  and  when  above  zero,  in  either  case,  add  32.  To  convert 
Fahrenheit  above  zero  into  Centigrade,  we  subtract  32,  multiply  by  6,  and  divide 
by  9. 

^  Internationa]  Medical  Magazine,  Dec.  1892. 


44  MEDICAL  DIAGNOSIS. 

and  every  degree  above  98°  F.  corresponds  with  an  increase  of 
ten  beats  of  the  pulse.  The  fever  temperature  ranges  from  100°  to 
106°.  When  it  exceeds  tliis,  the  patient  may  be  looked  upon  as  in 
great  danger,  except  the  rise  be  due  to  malarial  fever.  Under  these 
circumstances  it  is  rapid,  occurrmg  in  a  person  who  but  a  few  hours 
before  was  healthy.  In  typhoid  fever  a  temperature  of  105°  is  a 
proof  of  grave  disease.  In  some  severe  cases  of  yellow  fever  the 
heat  in  the  armpit  has  been  noted  as  108°.^  In  pneumonia  a  tem- 
perature above  104°  is  a  symptom  of  a  very  serious  seizure  ;  so,  too, 
is  it  m  acute  rheumatism  a  symptom  either  of  danger  or  of  some 
complication.  Stability  of  temperature  from  mornmg  to  evening  is  a 
good  sign ;  the  temperature  remaining  the  same  from  evening  till 
morning  is  a  sign  that  the  patient  is  getting  worse.  In  convalescence 
the  temperature  declmes  until  it  attams  its  norm,  or  even  falls  some- 
what below  this.  If  after  the  defervescence  the, thermometer  again 
indicate  a  decided  rise,  it  shows  a  return  of  the  malady,  or  the  super- 
vention of  some  complication  or  new  disorder ;  and  the  persistence 
of  even  a  slight  degree  of  abnormal  heat  after  apparent  convalescence 
is  a  sign  of  imperfect  recovery,  or  of  the  existence  of  some  Imgering 
secondary  complaint.  Further,  in  cases  of  low  fevers,  the  skin,  par- 
ticularly of  the  hands  and  feet,  may  feel  cool  at  the  same  time  that 
the  instrument  in  the  axilla  marks  104°. 

Specific  forms  of  febrile  diseases  have  their  characteristic  varia- 
tions of  temperature.  In  measles,  for  mstance,  the  temperature  rises 
towards  the  breaking  out  of  the  rash,  reaches  its  height  ^Yiih  the 
period  of  eruption,  and  m  the  twenty-four  hours  succeedmg  it  falls 
rapidly.  In  scarlet  fever  the  thermometer  marks  105°,  or  upward,  at 
the  begmning,  and  the  heat  only  gradually  subsides.  TyjDhoid  fever 
has  its  characteristic  record  ;  so  have  the  malarial  fevers  theirs.  The 
temjDerature  of  tetanus  rises  to  great  heights  before  death. 

A  temperature  about  107°  is  almost  certam  to  be  the  forermmer 
of  a  fatal  issue.  But  recovery  may  take  place.  In  a  case  of  cere- 
bral rheumatism  under  my  charge^  the  thermometer  marked  110° 
in  the  axilla,  yet  the  patient  got  well.  In  an  instance  of  injury  to  the 
spine  after  a  fall,  reported  by  Teale,^  the  young  lady  lived  though  the 
temperature  reached  above  122°  and  ranged  for  days  between  112° 
and  114°.  A  remarkable  case  has  also  been  reported  of  hysteria 
and  mtercostal   neuralgia,  in  which  in    one  axilla   the   temperature 


^  Wragg,  Charleston  Medical  Journal,  vol.  x. 

^  See  Amer.  Journ.  Med.  Sci.,  Jan.  1875. 

^  Transact.  Clinical  Society  of  London,  vol.  viii. 


EXAMINATION  OF  PATIENTS,  ETC.  45 

registered  117°  F.  and  in  the  other  110°,  but  the  patient  recovered.^ 
Galbraith  ^  has  reported  a  case  in  which  the  thermometer  registered 
151°,  and  Jones  ^  that  of  a  girl,  fourteen  years  of  age,  in  whom  the 
temperature  rose  to  over  150°.  In  neither  instance  was  the  extraor- 
dinary heat  attended  with  evil  results.  Duckworth  reports  *  a  case 
in  which  the  thermometer  marked  228°  (108.9°  C).  In  all  these  ex- 
traordinary temperatures  the  possibihty  of  deception  practised  by  hys- 
terical patients  must  be  borne  in  mind.  The  temperature  may  be 
temporarily  very  high  from  emotion.  I  saw  this  once  in  a  frightened 
child  which  had  previously  had  but  slight  fever,  and  E.  S.  Tail  has 
reported  the  same  in  the  puerperal  state.^ 

On  the  other  hand,  the  thermometer  may  show  a  depression  in 
temperature  below  the  normal.  The  body  heat  often  falls  at  the  be- 
ginning of  acute  peritonitis.  It  is  low  after  severe  loss  of  blood,  or  if 
exposure  to  cold  happen  in  alcoholic  intoxication,  during  convales- 
cence from  acute  diseases,  and  in  melancholia.  It  is  depressed  by 
various  poisons,  and  has  been  observed  down  to  93.9°  in  carbolic 
acid  poisoning.^  It  is  low  in  the  insane.  It  may  be  only  a  fraction 
above  89°  in  the  axilla  in  cholera.  From  any  other  cause  it  rarely, 
even  in  extreme  collapse,  sinks  below  92°. 

Though  having  its  widest  range  of  applicability  in  fevers,  in  other 
than  febrile  states,  too,  the  thermometer  assists  greatly  in  diagnosis 
and  prognosis.  It  is  invaluable,  in  many  instances,  in  discriminating 
between  functional  and  organic  affections.  It  aids  in  the  study  of 
apoplexy,  of  palsies,  and  of  hysterical  affections,  and  tells  the  true 
story  in  cases  of  feigned  disease.  It  also  enables  us  to  judge  whether 
increased  frequency  of  pulse  be  due  to  fever  or  to  debility ;  and  it 
indicates  that  sweating  which  is  not  preceded  by  a  previous  elevation 
of  temperature  is  the  result  of  exhaustion  and  not  of  fever.  There 
is  a  continuous  rise  of  the  heat  of  the  body  in  all  cases  in  which  a 
deposition  of  tubercle  is  taking  place  actively  in  any  of  its  organs, 
and  more  especially  in  the  lungs  ;  while,  on  the  other  hand,  I  have 
noticed  that  in  cancerous  affections  the  heat  of  the  body  is  but  little 
influenced,  and  is  sometimes  even  below  the  normal  standard. 

Tongue. — When  a  patient  is  told  to  put  out  his  tongue,  it  is  not 
to  see  whether  this  organ  is  the  seat  of  disease,  but  because  experi- 

^  Philipson,  London  Lancet,  April,  1880. 

^  Journ.  Amer.  Med.  Assoc,  March,  1892. 

»  Memphis  Medical  Monthly,  Oct.  1891. 

*  Archives  of  Gynaecology,  New  York,  Oct.  1891. 

^  Obst.  Soc.  Transact.,  1884. 

®  Baumler,  in  Quain's  Dictionary  of  Medicine. 


46  MEDICAL   DIAGNOSIS. 

ence  has  taught  that  the  tongue  is  a  mirror,  more  or  less  perfect,  of 
the  condition  of  the  digestive  functions,  and  that  it  reflects  the  com- 
jDlesion  of  the  ner^^ous  power  and  of  the  blood,  and  the  state  of  the 
secretions.  To  judge  of  these  varied  circumstances,  we  have  to  ex- 
amine tlie  tongue  in  regard  to  its  movements,  its  volume,  its  dryness 
or  its  humidity,  its  color,  and  its  coating. 

The  movements  of  the  tongue  are  impeded  and  tremulous  m  all 
conditions  of  the  system  attended  with  exhaustion.  It  is  protruded 
slowly  and  ^vith  difficulty  m  fevers  of  a  low  type,  and  m  nervous  dis- 
orders wliich  are  accompanied  by  marked  debihty.  The  action  of 
the  muscles  is  seriously  impaired  in  paralysis.  In  hemiplegia  one  side 
is  crippled,  and  the  tongue  turns  towards  one  of  the  corners  of  the 
mouth.  When  imperfect  articulation  is  associated  with  difficulty  in 
moving  the  oi^an,  it  commonly  announces  a  serious  cerebral  lesion. 

The  volume  of  the  tongue  is  changed  by  its  own  diseases ;  more 
rarely  by  the  condition  of  the  system  at  large,  or  by  cUsturbances 
of  the  abdominal  viscera.  Yet  a  swollen  or  a  broad  and  flabby  tongue, 
on  the  sides  of  which  the  teeth  leave  their  marks,  is  sometimes  found 
in  chronic  ailments  of  the  digestive  organs,  and  as  the  result  of  the 
action  of  mercury,  and  of  certam  poisons.  It  is  further  obsen^ed  in 
some  affections  of  the  brain,  or  as  a  consequence  of  a  disturbed  cir- 
culation attendmg  diseases  of  the  heart,  and  in  cUstempers,  like  the 
plague,  typhus,  or  scur^w.  m  wMch  the  blood  is  much  altered.  In 
affections  of  the  stomach  a  flabby  tongue  showing  marks  of  the  teeth 
is  a  sign  of  decreased  motility.  The  tongue  is  sometimes  observed 
to  be  swollen  on  one  side  only  in  consequence  of  catarrhal  inflam- 
mation. This  hemiglossitis  affects  the  left  side,  and  is  supposed  to  be 
of  neurotic  origin.^  Loss  of  substance  of  the  tongue,  especially  on 
its  borders,  is  mostly  due  to  s^'pliilis.  The  ulceration  is  often  asso- 
ciated with  fissures. 

Dryness  of  the  tongue  incUcates  deficient  salivary  secretion.  In 
acute  visceral  inflammations,  and  still  more  frequently  in  febrile  states, 
especially  in  the  exanthemata  and  in  typhoid  fever,  the  tongue  is  dry ; 
it  may  be  so  dry  as  to  cause  the  papillEe  to  become  prominent  and 
the  whole  organ  to  appear  roughened.  The  condition  is  one  wliich, 
in  acute  diseases,  is  always  to  be  dreaded,  especially  if  the  tongue  be, 
in  addition,  of  a  dark  color,  glazy,  or  furred  or  fissured ;  for  it  is 
then  a  proof  not  only  of  generally  arrested  secretions,  but  also  of 
depraved  blood  and  of  ebbing  life  force.  Yet  a  fissured  tongue  is  not, 
by  itself,  indicative  of  great  and  imminent  danger ;  it  may  occur  in 

^  Dyce  Duckworth,  Liverpool  Med.-Chir.  Journ.,  July,  1883. 


EXAMINATION   OF  PATIENTS,  ETC.  47 

chronic  affections  of  the  liver,  or  in  chronic  inflammation  of  the  in- 
testines ;  and  in  some  persons  it  is  congenital.  In  estimating  dryness 
of  the  tongue  we  must  not  overlook  the  fact  that  this  may  happen 
from  persistent  openness  of  the  mouth,  as  during  sleep,  from  obstruc- 
tion of  the  nasal  passages,  or  from  coma.  Among  chronic  diseases 
the  tongue  is  most  apt  to  be  found  dry  in  diabetes.  A  dry,  incrusted, 
brown  tongue  is  due  to  a  continuous  crust  on  and  between  the  papillae, 
which  is  filled  with  parasitic  growths.  It  occurs  in  states  of  pros- 
tration with  lowering  of  nutrition  and  tendency  to  sinking.  Dickinson 
has  calculated  that  a  dry  tongue  is  present  in  about  fifty  per  cent,  of 
fatal  cases ;  more  than  any  other  it  foretells  death.^  The  opposite 
of  dryness,  humidity^  is,  unless  excessive,  a  favorable  sign.  It  is  ex- 
tremely so  if  it  succeed  dryness,  because  it  is  a  proof  that  the  secre- 
tions are  being  re-established. 

There  is  a  rare  disease  of  the  tongue  known  as  xerostomia,  occur- 
ring in  women  after  middle  life,  in  which  the  dryness  of  the  tongue  is 
so  extreme  that  it  may  prevent  speaking  or  swallowing.  The  tongue 
is  cracked  like  alligator  skin,  and  looks  hke  raw  beef.^ 

The  color  of  the  tongue  is  subject  to  many  variations.  It  is  re- 
markably pale  whenever  the  blood  is  watery  and  deficient  in  red 
globules.  It  is  exceedingly  red  and  shining  in  the  exanthemata,  espe- 
cially in  scarlet  fever.  The  tongue  is  also  very  red  if  inflammation 
have  attacked  its  substance,  or  the  fauces,  or  the  pharynx.  It  is  bluish 
and  livid  when  there  is  an  obstruction  to  the  flow  of  the  venous 
blood  or  deficient  aeration,  as  in  some  structural  diseases  of  the  heart 
and  in  dangerous  cases  of  bronchitis  or  of  pneumonia.  A  red,  smooth 
tongue  is  a  sign  of  failing  nutrition.  A  tongue  black  in  spots,  the 
discoloration  particularly  marked  about  the  middle  of  the  dorsum, 
the  papillae  enlarged,  indicates  a  condition  of  parasitic  origin. 

As  important  as  the  color  of  the  organ  are  the  color  and  form  of 
its  coating.  In  health  the  tongue  has  hardly  a  discernible  lining ;  dis- 
ease quickly  gives  it  one.  In  inflammation  of  the  respiratory  textures, 
at  the  beginning  of  fevers,  in  disorders  of  large  portions  of  the  ab- 
dominal mucous  tract,  the  epithelium  accumulates,  and  the  tongue 
has  a  loaded,  whitish  appearance,  due  to  excess  of  white  epithelium 
on  the  papillae  with  the  intervals  also  more  or  less  fifled  up.  The 
coat  is  apt  to  be  yellowish  in  disturbances  of  the  liver,  and  of  a  brown 
or  a  very  dark  hue  when  the  blood  is  contaminated.     But  we  must 


^  The  Tongue  as  an  Indication  in  Disease,  London,  1888. 
^  See  reports  of  cases  in  Sajous's  Annual  of  the  Univ.  Med.  Sci.,  vol.  i.  1891, 
C-1. 


48  MEDICAL  DIAGNOSIS. 

be  sure,  in  drawing  our  inferences,  that  the  abnormal  aspect  is  not 
due  to  the  food  partaken  of  or  to  medicine.  Its  color  is  also  modified 
by  the  character  of  the  occupation.  Thus,  as  Chambers  tells  us, 
there  is  a  smooth,  orange-tinted  coating  on  the  tongues  of  tea-tasters. 
A  local  cause  sometimes  gives  rise  to  'a  thick,  opaque  coat.  For  in- 
stance, decayed  teeth  may  produce  a  yellow  sheathing  on  one  side. 
Affections  of  the  fauces  also  occasion  a  deep-yellow  hue.  Again, 
there  are  many  healthy  persons  who  wake  up  every  morning  with 
their  tongues  covered,  more  especially  at  the  back,  with  a  heavy 
coating,  which  wears  off  after  a  meal. 

In  some  diseases  the  epithelium,  which  is  either  formed  in  exces- 
sive quantities  or  not  thrown  off,  collects  between  the  papillae,  leaving 
them  uncovered  and  prominent.  This  is  especially  noticed  in  scrofu- 
lous children.  When  the  epithelium  is  sticky  and  adherent,  it  winds 
itself  chiefly  around  the  filiform  papillae,  elongating  them  and  giving 
to  the  surface  of  the  organ  2i  furred  appearance.  Although  this  kind 
of  tongue,  as  almost  every  other  variety,  is  met  with  now  and  then  in 
persons  who  are  not  ill,  yet  it  may  be  generally  looked  upon  as  de- 
noting disease.  It  occurs  sometimes  in  chronic  diseases  of  the  ab- 
dominal viscera,  but  much  oftener  in  grave  acute  maladies.  The 
tongue,  on  the  other  hand,  may  be  bare  of  its  epithelium  or  imper- 
fectly covered  with  it.  We  meet  with  this  in  certain  instances  of 
scurvy,  or  in  cases  of  chronic  diarrhoea  and  dysentery  with  great 
prostration,  in  which  the  tongue  is  often  found  to  be  red,  smooth,  and 
dry,  or  in  attendance  on  cachexias,  as  the  malarial.  Again,  a  denuded 
tongue  is  common  in  scarlet  fever,  and  not  infrequent  in  typhoid  fever. 
In  scarlet  fever  it  has  a  strawberry  look.  This  is  sometimes  also  seen 
in  pneumonia. 

The  state  of  the  digestion  and  the  character  of  the  discharges  have 
so  close  a  connection  with  the  nutrition  of  the  body  that  they  become 
important  general  symptoms.  But,  for  the  sake  of  convenience,  their 
value  will  be  inquired  into  while  discussing  the  diseases  in  the  recog- 
nition of  which  they  occupy  the  foremost  place.  A  few  words  here, 
however,  on  the  sensations  of  patients. 

Sensations  of  Patients. — Sick  persons  are  subject  to  many  dis- 
agreeable feelings.  They  complain  of  chills,  of  heat,  of  languor,  of 
restlessness,  and  of  uneasiness ;  but  their  most  constant  complaint  is 
of  pain.  Now,  pain  may  be  of  various  kinds  ;  it  may  be  dull  or 
gnawing ;  it  may  be  acute  and  lancinating.  In  its  duration  it  may  be 
permanent  or  remitting.  A  dull  pain  is  generally  persistent.  It  is 
most  often  present  in  congestions,  in  subacute  and  chronic  inflamma- 
tions, and  where  gradual  changes  of  tissue  are  taking  place.     It  is 


EXAMINATION   OF  PATIENTS,  ETC.  49 

the  pain  of  chronic  rheumatism,  and  shades  off  into  the  innumerable 
aches  of  this  malady.  The  only  acute  affections  in  which  it  is  apt 
to  exist  are  inflammations  of  the  parenchymatous  viscera  and  of 
mucous  membranes. 

Acute  pain  is  in  every  respect  the  reverse  of  dull  pain.  It  is  usually 
remittent,  and  not  so  fixed  to  one  spot.  It  is  met  with  in  spasmodic 
affections,  in  neuralgia,  and,  with  extremely  sharp  and  lancinating 
pangs,  in  malignant  disease. 

Pain  varies  much  in  intensity ;  it  is  sometimes  so  extreme  as  to 
cause  death.  We  have  to  judge  of  its  severity  partly  on  the  testimony 
of  the  sufferer,  partly  by  the  countenance,  and  partly  by  the  attending 
functional  disturbances.  The  latter  are  not  to  be  overlooked,  for  they 
enable  us,  to  some  extent,  to  appreciate  whether  the  torments  are  as 
great  as  they  are  represented  to  be. 

The  seat  to  which  the  pain  is  referred  is  far  from  being  always  the 
seat  of  the  disease.  A  calculus  in  the  bladder  may  produce  dragging 
sensations  extending  down  the  thighs  ;  inflammation  of  the  hip-joint 
gives  rise  to  pain  in  the  knee  ;  disorders  of  the  liver  occasion  pain 
in  the  right  shoulder.  Pain  felt  at  some  part  remote  from  that 
affected  is  either  transmitted  in  the  course  of  a  nerve  involved,  or 
is  sympathetic. 

The  same  abnormal  action  does  not  always  create  the  same  kind 
of  pain.  Inflammation,  for  instance,  causes  different  pain  as  it  in- 
volves different  structures  :  the  pain  from  an  inflamed  pleura  is  not 
the  same  as  that  from  an  inflamed  muscle.  Speaking  generally,  the 
tissues  themselves  seem  to  determine  the  form  of  pain  more  cer- 
tainly than  does  the  precise  character  of  the  morbid  process.  Thus, 
pain  in  diseases  of  the  periosteum  and  bones,  no  matter  what  may  be 
the  exact  nature  of  the  malady,  is  mostly  boring  and  constant ;  in  the 
serous  membranes,  sharp  ;  in  the  mucous  membranes,  dull ;  and  in 
the  skin,  burning  or  itching. 

Pain  produced  by  pressure  is  called  tenderness.  It  indicates  in- 
creased sensibility,  and  is  most  constantly  associated  with  inflamma- 
tion. Yet  tenderness  may  be  present  without  inflammation ;  the 
tenderness,  for  example,  of  the  skin  in  hysteria.  Commonly  it  is 
combined  with  pain  occurring  independently  of  pressure  ;  but  a  part 
may  be  tender  and  not  painful. 


CHAPTER   II. 

DISEASES   OF   THE  BRAIN  AND   SPINAL   CORD,    AND  OF   THEIR 

NERVES. 

Before  entering  upon  a  consideration  of  the  affections  of  the 
nervous  system  it  is  proper  to  recall  a  few  salient  points  connected 
with  its  structure  and  functions  indispensable  to  a  recognition  of  its 
derangements.  We  have  constantly  to  bear  in  mind  that  there  are  in 
its  composition  nerve-cells  composing  ganglia,  which  are  for  the  most 
part  originators,  and  nerve-fibres,  which  are  for  the  most  part  con- 
ductors, and  besides,  a  peripheral  termination  of  these  conductors, 
which  forms  a  peripheral  nervous  system,  chiefly  concerned  in  re- 
ceiving and  distributing  impressions.  Then,  too,  of  late  years  much 
stress  has  been  laid  upon  the  nerve-cells,  including  the  ceh-body  and 
its  processes,  and  for  each  of  these  separate  cell  units  the  name  neu- 
ron has  been  adopted.  The  most  important  process  of  the  nerve- 
cell  is  the  axis-cylinder,  or  the  neuraxon.  In  the  brain  and  spinal 
cord  are  the  principal  nervous  centres  which  originate  and  control, 
and  of  the  brain  especially  our  knowledge  of  the  subject  of  locali- 
zation and  special  function  of  particular  points  has  become  so  ex- 
tended that  it  is  made  the  basis  of  accurate  diagnostic  knowledge, 
which  has  of  late  years  assumed  the  greatest  practical  importance. 

Cerehi^al  Localization. 

A  knowledge  of  the  centres  in  the  brain  is  a  necessity  for  both 
diagnostic  and  surgical  purposes.  This  knowledge  has  been  acquired 
in  part  by  experimental  observations  upon  the  lower  animals,  in  part 
by  clinical  and  pathological  observations,  and  in  part  by  electrical 
stimulation  of  areas  of  the  cortex  in  the  course  of  surgical  operations 
upon  human  beings. 

The  localization  of  human  cortical  centres  is  indicated  in  the  an- 
nexed sketch.  It  should  not  be  forgotten  that  in  all  such  diagram- 
matic representations  the  picture  represents  the  fact  but  poorly.  The 
two  halves  of  the  same  brain  are  unlike.  Moreover,  there  is  never 
any  hard  and  fast  line  dividing  one  centre  from  its  neighbor.  If  they 
50 


DISEASES  OF  THE  BRAIN  AND   SPINAL  CORD.  51 

do  not  actually  overlap,  the  centres  certainly  pass  into  one  another 
by  indefinable  gradations.  The  strength  of  the  stimulus  modifies 
the  defmiteness  of  limitation,  and  many  facts  go  to  show  that  the 
unaffected  hemisphere  has  often  a  certain  power  of  substitution, 
whereby  it  can  take  up  the  function  of  its  injured  fellow.  It  must 
be  borne  in  mind  that  not  muscles  but  movements  have  cortical 
representation,  and  that  movements  on  each  side  of  the  body  are 
represented  in  the  cortex  of  both  sides  of  the  cerebrum,  though  in 
preponderant  degree  in  that  of  the  opposite  side.  On  the  other 
hand,  there  is,  at  least  in  the  case  of  articulate  speech,  a  location 
of  the  unique  controlling  centre  singly  upon  one  side  or  the  other 
according  as  the  person  is  right-handed  or  left-handed. 

The  prefrontal  region — i.e.,  that  anterior  to  the  motor  area — is 
the  seat  of  the  higher  mental  processes.  The  movements  of  the 
lower  extremities  are  represented  in  the  upper  fourth  of  both  cere- 
bral convolutions,  the  gray  matter  concerned  extending  in  a  mesial 
direction  to  the  paracentral  lobule,  posteriorly  to  the  superior  parietal 
lobule  and  anteriorly  to  the  first  frontal. 

Movements  of  the  hip  and  knee  are  localized  near  the  centres  for 
the  shoulder-movements ;  movements  of  the  great  toe  somewhat 
above,  at  about  the  junction  of  the  middle  and  posterior  thirds  of  the 
leg  area ;  movements  of  the  other  toes  still  farther  back  ;  movements 
of,  the  ankle  between  the  areas  for  knee  and  great  toe.  Movements 
of  the  spine  and  trunk  are  most  strongly  represented  in  the  mesial 
aspect  of  the  hemisphere  in  advance  of  the  area  for  the  movements 
of  the  lower  extremity. 

The  cortical  area  governing  the  movements  of  the  upper  extrem- 
ities occupies  the  middle  two  fourths  of  the  central  convolutions, 
extending  posteriorly  to  the  interparietal  fissure  and  anteriorly  to 
the  frontal  convolutions.  This  area  contains  from  above  downward 
subareas  for  the  movements  of  the  shoulder,  elbow,  wrist,  thumb, 
and  fingers  respectively. 

The  area  in  which  are  represented  the  movements  of  the  head 
occupies  the  lower  fourth  of  the  central  convolutions,  including  the 
entire  operculum,  with  the  posterior  portion  of  the  third  frontal  and 
the  dorsal  lip  of  the  fissure  of  Sylvius.  The  movements  represented 
in  this  area,  from  above  downward,  are  the  orbiculo-palpebral,  those 
of  the  angle  of  the  mouth,  and  those  of  the  lips  and  tongue.  The 
movements  of  the  platysma  are  probably  represented  in  the  posterior 
and  inferior  portion  of  this  area.  The  centres  for  the  movements  of 
the  larynx  and  pharynx  are  located  in  the  anterior  part  of  the  lower- 
most portion  of  the  anterior  central  convolution,  and  behind  it  is  the 


52 


MEDICAL  DIAGNOSIS. 


centre  for  the  movements  of  the  lower  jaw.     Those  of  the  head  and 
eyes  are  in  the  most  anterior  portion  of  the  motor  zone. 

In  the  lowest  portion  of  the  ascending   frontal  convolution,  and 


€  9 


extending  into  the  posterior  portion  of  the  third  left  frontal  convo- 
lution, lies  the  centre  for  articulate  speech,  lesion  of  which  causes 
motor  aphasia.     This  is  usually,  though  not  always,  associated  with 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD. 


53 


inability  to  express  thoughts  in  writing, — agraphia.  But  our  complex 
power  of  thought-expression  is  made  up  of  two  other  elements  that 
are  sensory ;  there  must  be  psychical  comprehension  both  of  the 
heard  and  of  the  seen  word.  The  centres  intermediating  these 
functions  have  been  made  out  with  some  approach  to  defmiteness. 
Lesions  of  the  first  temporal  convolution  produce  word-deafness,  or 
inability  to  comprehend  the  meaning  of  words  though  not  deaf  to 
other  sounds.  In  the  same  way,  word-blindness,  or  inability  to 
understand  the  import  of  written  or  printed  words,  follows  injury 
of  the  angular  gyrus. 

Ficx.  10. 


Right  Homonymous  or  Lateral  Hemianopsia,  from  Lesion  of  the  Left  Visual  Centre  of 
THE  Cortex  or  Left  Optic  Tract. — A,  dark  left  nasal  half-field  from  blind  temporal  half  of  retina ; 
A',  dark  right  temporal  half-field  from  blind  nasal  half  of  retina ;  B,  left  eye ;  B',  right  eye ;  C,  C", 
left  and  right  optic  nerves,  composed  of  the  crossed  bundles  of  fibres ;  D,  D',  left  and  right  crossed 
bundles ;  E,  E',  left  and  right  occipital  lobes ;  F,  F',  left  and  right  iposterior  cornua ;  G,  G',  "  optic 
radiation"  of  Gratiolet;  H,  H',  optic  chiasm;  /,  I',  angular  gyrus;  K,  region  of  optic  thalamus, 
geniculate  body,  and  quadrigeminal  bodies,  collectively  termed  the  primary  optic  centres ;  M,  M', 
cuneus  of  the  occipital  lobe,  the  cortical  visual  centre.  The  left  cuneus  and  optic  tract  are  shaded, 
to  show  lesion  of  these  parts  and  the  influence  of  the  lesion  upon  the  retinse. 

In  reference  to  the  cortical  visual  centre  there  can  be  little  doubt 
that  it  is  located  in  the  occipital  lobe,  and  especially  in  the  cuneus. 
The  production  of  hemianopsia  from  lesions  of  the  occipital  lobe,  in 
accordance  with  the  conclusions  of  Seguin,^  is  shown  in  the  accom- 
panying diagram  (Fig.  10).  Complete  cortical  blindness  may  be  con- 
sidered as  a  bilateral  hemianopsia.     The  macula  is  also  represented 


Journal  of  Nervous  and  Mental  Diseases,  1886,  No.  1,  and  Nov.  1887. 

4 


54  MEDICAL  DIAGNOSIS. 

in  the  cortex.  Dimness  of  sight  in  the  opposite  eye,  with,  -as  a  rule, 
concentric  dimmution  of  the  field,  or  crossed  amblyopia,  depends 
upon  a  lesion  in  the  angular  gyrus. 

The  auditory  centre  is  most  likely  in  the  middle  of  the  first  tem- 
poro-sphenoidal  convolution  and  related  to  the  auditory  nerve  of  the 
opposite  side.  The  centre  for  smell  is  very  probably  on  the  medial 
surface  of  the  temporal  lobe  at  the  anterior  extremity  of  the  uncinate 
convolution  and  in  connection  with  the  olfactory  nerve  of  the  same 
side.  The  cortical  centre  for  taste  is  referred  to  the  hmbic  lobe. 
The  location  of  the  centres  for  tactile  or  cutaneous  sensation  is  also 
in  dispute,  but  it  appears  probable  that,  if  not  identical  with,  they  are 
at  least  contiguous  to  those  of  the  motor  functions  of  corresponding 
parts.^  The  muscular  sense  and  the  stereognostic  sense  seem  to  be 
represented  especially  in  the  cortex  of  the  motor  and  parietal  convo- 
lutions. A  geographical  centre,  a  centre  for  determining  locality,  is 
claimed  to  have  its  seat  in  the  occipital  lobe,  near  the  visual  centre ; 
a  naming  centre  has  been  located  in  the  third  temporal  convolution, 
and  a  writing  centre  in  the  second  frontal  convolution.  The  psy- 
chical, or  mental,  processes  have  as  their  centres  those  parts  of  the 
cortex  that  have  not  been  found  to  possess  any  special  motor  or 
sensory  function,  and  particularly  the  prefrontal  lobes. 

It  is  often  a  matter  of  much  importance,  especially  with  reference 
to  brain  surgery,  to  determine  on  the  skull  the  seat  of  the  underlying 
cerebral  centres.  Broca,  Horsley,  and  Reid  have  especially  mvesti- 
gated  the  subject,  and  from  their  and  other  researches  we  are  sure  of 
these  facts  : 

Under  the  frontal  bone  lie  almost  the  entire  frontal,  middle,  and 
about  three-quarters  of  the  upper  frontal  convolutions.  The  tem- 
poral bone  covers  the  temporal  lobe,  except  its  anterior  extremity 
and  its  posterior  fifth.  The  occipital  bone  covers  the  greater  part  of 
the  occipital  lobe ;  the  remainder  of  the  cortex  is  beneath  the  parietal 
bone.  The  ascending  frontal  convolution  starts  somewhat  lower  that 
beneath  the  anterior  inferior  angle  of  the  parietal  bone  in  front  of  the 
prolonged  line  of  the  fissure  of  Rolando.  In  front  of  the  precentral 
sulcus,  the  lower  half  of  which  is  parallel  to  and  behind  the  coronal 
suture,  lies  the  root  of  the  lower  frontal ;  the  root  of  the  ascending 
parietal  is  behind  the  ascending  frontal.  The  upper  end  of  the  fissure 
of  Rolando  corresponds  to  a  point  half  an  inch  behind  the  middle  of 
a  line  measured  from  the  root  of  the  nose  upward  to  the  occipital 
protuberance,  and  the  fissure  extends  obliquely  downward  and  for- 

^  See  Dana,  Journal  of  Nervous  and  Mental  Diseases,  Oct.  1888. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  55 

ward,  at  "an  angle  of  67  degrees,  to  within  a  short  distance  of  the  fork 
of  the  Sylvian  fissure.  The  fissure  between  the  middle  and  lowest 
frontal  convolutions  is  under  the  temporal  ridge.  The  central  con- 
volutions are  about  an  inch  on  each  side  of  the  fissure  of  Rolando ; 
the  centres  for  the  leg,  arm,  and  face  lie  on  each  side  of  the  fissure. 
The  angular  gyrus  is  immediately  behind  the  most  prominent  portion 
of  the  parietal  eminence.  The  first  temporal  convolution  is  over  the 
ear  and  mastoid  process  below  the  Sylvian  line.  This  situation  is 
determined  by  drawing  a  line  from  the  external  angular  process  of 
the  frontal  bone  to  a  point  three-quarters  of  an  inch  below  the  most 
prominent  part  of  the  parietal  bone. 

Sensory  Centres^  and  Conducting  Paths. 

The  sensory  centres  and  the  conducting  paths  by  which  the  fibres 
unite  the  various  parts  of  the  brain,  whether  sensory  or  motor,  and 
of  the  spinal  cord,  are  not  so  definitely  made  out  as  the  brain-centres 
have  been  ;  particularly  uncertain  are  we  as  to  the  course  of  the 
sensory  paths  in  the  medulla,  pons,  and  peduncle. 

The  sensory  centres  for  the  muscular  sense  and  the  sense  of  touch 
are  supposed  by  Horsley  and  others  to  be  in  layers  of  cells  in  the 
motor  cortex.  But  the  centres  for  sensory  impression  are  also  claimed 
to  be  the  hippocampal  convolution  and  the  gyrus  fornicatus,  and, 
generally,  the  occipital  and  temporo-sphenoidal  lobes. 

Volitional  impulses  originate  in  the  motor  cortex,  and  pass  by 
converging  fibres  through  the  white  substance  of  the  hemisphere  to 
the  internal  capsule,  thence  beneath  the  optic  thalamus,  to  enter  the 
crus  cerebri,  and  through  the  pons,  reaching  the  medulla,  where  the 
larger  number  of  fibres  cross  to  the  opposite  side  of  the  cord  to  form 
the  lateral  or  crossed  pyramidal  tract.  The  smaller  fibres  that  con- 
tinue onward  form  the  anterior  or  direct  pyramidal  tract ;  these  de- 
cussate in  the  cord  at  various  levels.  This  constitutes  the  upper 
segment  of  the  motor  path  of  Gowers,  which  terminates  in  the  gan- 
glion-cells of  the  anterior  horns  of  the  cord.  The  lower  segment 
consists  in  the  fibres  that  originate  in  the  efferent  processes  of  the 
ganglion-cells  and  pass  to  their  peripheral  distribution  in  the  muscles. 

The  fibres  for  the  so-called  cranial  nerves  leave  the  pyramidal 
columns  as  they  approach  the  level  of  their  nuclei  on  the  opposite 
side  of  the  medulla,  to  reach  which  they  cross  the  median  line  some- 
what in  advance  of  the  decussation  of  the  remainder  of  the  pyramidal 
tracts. 

A  lesion  in  any  part  of  the  upper  segment  of  the  motor  path,  be- 
tween the  cortical  cells  and  the  ganglion-cells  of  the  anterior  horns, 


56  MEDICAL  DIAGNOSIS. 

is  followed  by  descending  degeneration  in  the  pyramidal  tracts.  The 
resultmg  paralysis  is  attended  with  increased  reflexes,  unchanged  or 
but  slightly  changed  electrical  reactions,  and  little  or  no  wasting  of 
the  muscles.  A  lesion  in  any  part  of  the  lower  segment,  between 
the  gray  matter  in  the  cord  and  the  terminations  of  the  nerves  in  the 
muscles,  gives  rise  to  paralysis  characterized  by  wasting,  qualitative 
electrical  changes,  and  impairment  or  abolition  of  the  reflexes. 

Sensory  impressions  reach  the  brain  through  the  posterior  roots 
of  the  cord,  passing  by  the  posterior  and  lateral  columns  in  several 
tracts,  most  of  which  decussate  in  the  cord.  The  sensory  fibres  for 
the  muscular  sense  are  supposed  not  to  decussate  in  the  cord,  but  in 
the  medulla. 

There  is  reason  to  believe  that  the  paths  for  common  tactile  im- 
pressions, for  painful  impressions,  for  the  conveyance  of  thermal 
impressions,  and  of  the  muscular  sense,  are  distinct  ;  that  for  the  first 
coursing  through  the  posterior  column,  those  for  the  second  and  third 
through  the  antero-lateral  ascending  tract,  and  those  for  the  last 
through  the  postero-median  column  and  the  direct  cerebellar  tracts. 

Lesions  of  the  peripheral  sensory  segment  are  attended,  in  addition 

to  the  impairment  of  sensibility,  with  abohtion  of  the  related  reflexes. 

Lesions  of  the  cord  involving  the  posterior  and  lateral  columns  are 

attended  ^Yiih  ascending  degeneration  in  the  postero-median  and  pos- 

tero-external  columns,  the  direct  cerebellar   and   the   antero-lateral 

ascending  tracts. 

Spinal  Localization . 

A  centre  for  spasm  is  thought  to  be  in  the  medulla  at  its  junction 
with  the  pons,  and  is  carried  by  the  vagus  ;  the  cardio-inhibitory  centre 
is  in  the  medulla ;  the  respiratory  centre  is  in  the  medulla  between 
the  nuclei  of  the  vagus  and  accessorius  ;  the  vasomotor  centre  is  in 
the  medulla ;  so  is  the  sweat-centre  in  the  medulla,  with  subordinate 
spinal  centres. 

The  following  facts  will  prove  useful  in  localizing  or  determining 
the  extent  of  a  lesion  of  the  spinal  cord :  Paralysis  of  the  small  rota- 
tors of  the  head  and  of  the  depressors  of  the  hyoid  bone  points  to 
involvement  of  the  first  and  second  cervical  nerves  ;  paralysis  of  the 
levator  anguli  scapulae  to  involvement  of  the  third  cenical ;  paralysis 
of  the  sterno-mastoid,  of  the  upper  neck-muscles,  and  of  the  upper 
part  of  the  trapezius  to  involvement  of  second,  tliird,  fourth,  and  fifth 
cervical ;  paralysis  of  the  diaphragm  to  involvement  of  the  fourth 
and  fifth  cervical ;  paralysis  of  the  serratus,  flexors  of  the  elbow,  and 
supinators  of  the  forearm  to  involvement  of  the  fifth  and  sixth  cervi- 
cal ;  paralysis  of  the  shoulder-muscles  to  involvement  of  the  fourth. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  57 

fifth,  and  sixth  cervical  ;  paralysis  of  the  extensors  of  the  wrist  and 
fingers  to  involvement  of  the  sixth  and  seventh  cervical ;  paralysis  of 
the  extensors  of  the  elbow,  of  the  flexors  of  the  wrist  and  fingers,  and 
of  the  pronators  of  the  forearm  to  involvement  of  the  seventh  and 
eighth  cervical ;  paralysis  of  the  lower  neck-muscles  and  of  the  middle 
part  of  the  trapezius  to  involvement  of  the  sixth,  seventh,  and  eighth 
cervical  and  first  dorsal ;  paralysis  of  the  muscles  of  the  hand  to  in- 
volvement of  the  eighth  cervical  and  first  dorsal ;  paralysis  of  the 
intercostals  to  involvement  of  the  dorsal  nerves  from  the  first  to  the 
tenth ;  paralysis  of  the  lower  part  of  the  trapezius  and  of  the  dorsal 
muscles  to  involvement  of  the  dorsal  nerves  from  the  second  to  the 
twelfth ;  paralysis  of  the  abdominal  muscles  to  involvement  of  the 
dorsal  nerves  from  the  seventh  to  the  twelfth,  and  also  the  first  lum- 
bar ;  paralysis  of  the  cremaster  and  flexors  of  the  hip  to  involvement 
of  the  second  and  third  lumbar ;  paralysis  of  the  extensors  of  the 
knee,  of  the  adductors,  extensors,  and  abductors  of  the  hip  to  involve- 
ment of  the  fourth  and  fifth  lumbar ;  paralysis  of  the  lumbar  muscles 
to  involvement  of  the  second,  third,  fourth,  and  fifth  lumbar  nerves  ; 
paralysis  of  the  peroneus  longus,  the  flexors  and  extensors  of  the 
ankle  to  involvement  of  the  fourth  and  fifth  lumbar  and  first  sacral 
nerves ;  paralysis  of  the  flexors  of  the  knee  to  involvement  of  the 
fifth  lumbar  and  first  sacral ;  paralysis  of  the  intrinsic  muscles  of  the 
foot  to  involvement  of  the  first  and  second  sacral ;  paralysis  of  the 
perineal  and  anal  muscles  to  involvement  of  the  third  and  fourth 
sacral  nerves. 

Loss  of  sensibility  on  the  scalp  points  to  involvement  of  the  first, 
second,  and  third  cervical  nerves  ;  on  the  neck  and  upper  part  of  the 
chest  to  involvement  of  the  second,  third,  fourth,  and  fifth ;  on  the 
shoulder  to  involvement  of  the  fourth  and  fifth ;  on  the  outer  aspect 
of  the  arm  to  involvement  of  the  fifth  and  sixth ;  on  the  radial  aspect 
of  the  forearm  and  hand  and  on  the  thumb  to  involvement  of  the 
sixth  and  seventh ;  on  the  inner  aspect  of  the  arm,  on  the  ulnar 
aspect  of  the  forearm  and  hand,  and  on  the  tips  of  the  fingers  to  in- 
volvement of  the  seventh  and  eighth  cervical  and  first  dorsal ;  on  the 
front  of  the  thorax  to  involvement  of  the  dorsal  nerves  from  the  first 
to  the  tenth ;  over  the  ensiform  cartilage  to  involvement  of  the  sixth 
and  seventh  dorsal ;  on  the  abdomen  to  involvement  of  the  dorsal 
nerves  from  the  seventh  to  the  twelfth,  and  also  the  first  lumbar ;  at 
the  umbilicus  to  involvement  of  the  tenth  dorsal ;  on  the  upper  part 
of  the  buttock  to  involvement  of  the  twelfth  dorsal  and  first  lumbar ; 
in  the  groin  and  on  the  scrotum  to  involvement  of  the  first  and  second 
lumbar ;  on  the  outer,  anterior,  and  inner  aspect  of  the  thigh  to  in- 


58  MEDICAL  DIAGNOSIS. 

volvement  of  the  second,  third,  fourth,  and  fifth  lumbar  nerves  ;  on 
the  inner  aspect  of  the  leg  to  involvement  of  the  fifth  lumbar ;  on  the 
lower  part  of  the  buttock,  on  the  posterior  aspect  of  the  thigh,  and 
on  the  anterior,  posterior,  outer  aspect  of  the  leg  and  foot  to  involve- 
ment of  the  fifth  lumbar  and  the  first,  second,  and  third  sacral ;  on 
the  perineum  and  about  the  anus  to  involvement  of  the  third,  fourth, 
and  fifth  sacral ;  and  on  the  skin  between  the  coccyx  and  anus  to  in- 
volvement of  the  fifth  sacral  and  the  coccygeal  nerves. 

Loss  of  the  scapular  reflex  points  to  involvement  of  the  fifth,  sixth, 
seventh,  and  eighth  cervical  and  first  dorsal  nerves  ;  of  the  epigastric 
reflex  to  involvement  of  the  fourth,  fifth,  sixth,  and  seventh  dorsal ; 
of  the  abdominal  reflex  to  involvement  of  the  dorsal  nerves  from  the 
eighth  to  the  twelfth,  and  also  the  first  lumbar  nerve ;  of  the  cre- 
master  to  involvement  of  the  first,  second,  and  third  lumbar ;'  of  the 
knee-jerk  to  involvement  of  the  second,  third,  and  fourth  lumbar ; 
of  the  gluteal  to  involvement  of  the  fourth  and  fifth  lumbar  and  the 
first  sacral ;  of  ankle-clonus  to  involvement  of  the  fifth  lumbar  and 
first  sacral ;  and  of  the  plantar  to  involvement  of  the  first,  second, 
and  third  sacral  nerves. 

Let  us  now  look  at  the  derangements  of  the  nervous  system.  But 
first  let  us  examine  a  few  symptoms  and  morbid  states  having  a 
general  significance  rather  than  a  specific  connection  with  any 
malady. 

Temperature  Variations. — These  are  not  uncommonly  induced  by 
organic  disease  of  the  brain.  Elevation  may  take  place  indepen- 
dently of  febrile  disease,  as  from  irritation  of  the  striate  body  or  of 
portions  of  the  cortex,  and  in  conjunction  with  hemorrhage  into 
the  pons  or  medulla,  vascular  obstruction,  and  the  epileptiform  and 
apoplectiform  attacks  of  general  paralysis.  The  temperature  is  ele- 
vated also  when  infectious  or  inflammatory  disease  of  the  brain  is 
present,  such  as  tubercle  or  abscess,  or  meningitis.  On  the  other 
hand,  organic  disease  of  the  bram  is  often  seen  with  subnormal 
temperature,  for  instance,  extensive  arteriosclerosis,  old  softening, 
and  general  paralysis. 

Ciroulatoi^y  Phenomena. — Apart  from  febrile  complications  the 
pulse  may  be  accelerated  in  disease  of  the  medulla,  or  of  degenera- 
tion in  or  about  the  vagus  nucleus,  or  in  consequence  of  irritation 
of  portions  of  the  cortex.  Irritation  of  the  vagus  nucleus  induces 
retardation  of  the  pulse.  This  may  result  directly,  as  from  inflam- 
matory processes  in  or  about  the  pons  and  medulla ;  or  indirectly,  as 
from  increased  intracranial  pressure,  such  as  attends  hydrocephalus, 
haematoma  of  the  dura  mater,  ventricular  hemorrhage,  brain  tumor. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  59 

or  from  meningeal  irritation  or  other  reflex  influence.  The  pulse  fre- 
quency may  be  reduced  to  40.  Acceleration  succeeding  retardation 
is  of  unfavorable  prognostic  import. 

Respiratory  Disturbances. — These  are  observed  together  with  coma, 
especially  in  disease  of  the  medulla  oblongata.  The  breathing  may  be 
accelerated  and  shallow,  sometimes  with  intermissions ;  but  more 
commonly  it  is  slowed  and  deepened,  and  the  pulse  also  is  slowed. 
The  breathing  may  be  stertorous,  or  assume  the  Cheyne-Stokes  type. 
In  deciding  that  the  respiratory  derangement  is  from  brain  disturbance 
care  must  be  taken  to  exclude  disease  of  the  lungs,  of  the  heart,  and 
of  the  kidneys. 

Vomiting. — When  of  cerebral  origin  vomiting  is  unattended  with 
pain,  nausea,  or  retching,  and  while  it  may  be  induced  by  food,  it 
often  occurs  independently  of  the  taking  and  also  of  the  character  of 
the  food.  It  may  result  through  reflex  influences,  as  from  meningeal 
irritation,  or  through  direct  irritation  of  the  vagus  nucleus,  from  in- 
creased intracranial  pressure  and  in  coma.  It  is  especially  common 
in  association  with  disease  of  the  medulla,  and  particularly  with 
tumors  of  the  posterior  fossa  of  the  base  of  the  skull. 

The  more  direct  symptoms  of  disorder  of  the  nervous  centres  are 
manifestations  of  deranged  intellection  and  deranged  sensation. 

DERANGED  INTELLECTION. 

The  great  instrument  of  the  intelligence,  the  brain,  manifests  its 
disorders,  whether  primary  or  merely  sympathetic,  by  derangement 
of  thought  of  every  conceivable  degree  and  kind, — from  dulness  and 
confusion  of  the  intellect  to  its  utter  perversion  and  prostration. 
When  one  intellectual  function  is  disturbed,  generally  all  are,  or  soon 
become  so ;  yet  we  may  find  impairment  of  judgment  and  of  imagi- 
nation without  deterioration  of  memory  or  of  the  powers  of  attention. 
One  of  the  most  marked  signs  of  mental  infirmity  is  an  impaired 
memory.  This  is  especially  encountered  in  chronic  cerebral  diseases, 
or  in  such  nervous  affections  of  uncertain  seat  as  epilepsy.  Another 
signal  of  mental  derangement  is  loss  of  judgment,  or  rather  loss  of 
power  to  appreciate  the  logical  sequence  of  ideas  ;  still  another  is 
depression  of  mind,  or  its  opposite,  exaltation.  All  these  abnormal 
conditions  may  happen  in  acute  as  well  as  in  chronic  maladies,  but 
they  are  more  striking  in  the  latter,  and  afford  more  aid  in  the  diag- 
nosis ;  and  they  may  or  may  not  be  joined  to  appreciable  textural 
changes.  To  the  psychologist  their  significance  is  very  great,  as  they 
are  often  the  premonitory  symptoms  of  that  departure  from  mental 
health  which  terminates  in  confirmed  insanity. 


60  MEDICAL  DIAGNOSIS. 

In  acute  disturbances  of  the  brain  delirium,  stupor  or  coma,  and 
insomnia  are  often  prominent  symptoms. 

Delirium.. — This  is  a  wandering  of  the  mind,  manifesting  itself  by 
the  expression  of  Ul-associated  thoughts,  of  the  incongruity  of  which 
the  patient  is  not  conscious.  It  occurs  most  frequently  in  those 
of  susceptible  nervous  system,  and  is  more  common  in  the  young 
than  in  the  old.  It  is  almost  invariably  united  with  restlessness,  and 
increases  as  night  approaches. 

The  character  of  the  delirium  is  various.  There  is  first  the  quiet 
delirium,  of  a  low  or  passive  type.  The  patient  mutters  incoherent 
words,  moans  ^^athout  any  assignable  reason,  or  lies  silent,  with  liis 
eyes  open,  his  mind  occupied  with  his  vague  illusions,  and  taking  no 
notice  of  what  goes  on  around  him.  If  strongly  aroused,  he  gives  a 
rational  answer,  but  not  a  long  or  a  connected  one,  for  he  soon 
returns  to  his  dreams  and  his  ever-changing  hallucinations.  He  picks 
at  his  bedclothes,  moves  in  bed,  and  may  even  try  to  leave  it, 
although  he  is  easily  prevented  from  so  doing. 

Then  there  is  a  delirium  of  somewhat  more  active  type,  still,  on 
the  whole,  quiet ;  the  patient  wanders,  yet  not  boisterously.  He  is 
irritable,  and  often  does  not  show  that  his  mind  is  disturbed,  except 
in  some  one  particular, — in  irascibility  about  trifles,  or  in  expressions 
and  modes  of  thought  foreign  to  his  nature. 

An  active,  fierce  delirium  presents  different  characteristics.  The 
patient  is  wild,  noisy ;  he  sings,  screams,  gets  out  of  bed ;  his  face 
during  the  excitement  becomes  congested ;  the  eye  is  bright,  often 
fiery. 

Now,  all  these  forms  of  delirium  occur  in  many  different  mala- 
dies, and  are  far  from  being  of  necessity  linked  to  an  organic  cerebral 
affection.  As  a  rule,  we  find  the  low,  quiet  delirium  in  conditions  of 
vital  exhaustion,  particularly  in  those  depressed  states  of  the  nervous 
system  which  are  connected  with  quickened  vascular  action,  and 
with  a  deterioration  of  the  blood,  as,  for  instance,  in  the  low  fevers. 
The  fierce  delirium  may,  however,  be  associated  Avith  prostration  or 
depraved  blood.  Thus,  the  delirium  of  pneumonia  is  sometimes  of  a 
violent  kind,  omng  to  the  maddening  effect  of  the  ill-oxygenated  blood 
on  the  brain.  In  most  of  the  ordinary  fevers  the  delirium  is  of  a 
moderate  type ;  in  inflammatory  diseases  of  the  brain  and  in  acute 
mania  it  is  fierce.  Tlie  delirium  of  uraemia  is  apt  to  be  active.  If 
the  delirium  be  due  to  cerebral  disease,  it  is  associated  with  head- 
ache ;  the  headache  of  pyrexia  generally  disappears  with  tlie  onset  of 
delirium. 

Delirium  is  not  difficult  of  recognition ;  yet  we  must  be  careful 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  61 

not  to  confound  with  it  night  terrors,  those  troubled  dreams  to  which 
ailing  children  are  so  liable,  and  which  occasion  confusion  of  thought 
on  first  awaking,  and  until  consciousness  is  fully  aroused.  Delirium 
is  most  likely  to  be  mistaken  for  insanity.  There  is  this  palpable  dif- 
ference :  an  insane  person  is  commonly  in  good  health  in  all  save  his 
intellect ;  a  delirious  person  is  ill,  and  exhibits  evidences  of  his  illness 
besides  his  delirium.  It  is  true  that,  when  the  patient  is  first  seen, 
doubt  may  arise ;  but  it  is  not  of  long  duration.  In  the  mania  ap- 
pearing occasionally  after  epileptic  fits,  or  taking  their  place,  there 
may  be  doubt  until  we  obtain  a  clear  history.  Most  perplexing  are 
the  cases  in  which  insanity  follows  or  attends  inordinate  drinking. 
But  this  is  a  subject  which  we  shall  discuss  in  reviewing  mania  a 
potu. 

Another  perplexing  group  of  cases  is  furnished  by  the  occurrence 
of  that  singular  form  of  delirium  which  has  been  called  the  delirium 
of  inanition,  or  of  collapse.  Its  outbreak  is  sudden,  like  an  attack  of 
mania,  but  it  is  found  to  be  combined  with  a  feeble  pulse,  with  a  skin 
bathed  in  jDerspiration,  with  cold  hands  and  feet, — in  a  word,  with 
the  signs  of  great  prostration  or  of  collapse.  The  seizure  happens 
usually  early  in  the  morning,  and  is  unexpected,  for  it  occurs  com- 
monly at  the  end  of  the  febrile  state,  and  when  the  condition  of  the 
skin  and  pulse  bespeaks  convalescence.  The  exhausted  nervous 
centre  betrays  itself  in  the  sudden  mental  wandering,  which  has 
generally  this  characteristic, — there  is  but  one  fixed  delusion,  and 
this  one  connected  with  the  subjects  which  have  most  engrossed  the 
mind  before  the  illness.  The  seizure  lasts  from  six  to  forty-eight 
hours,  and  at  its  termination  the  patient  is  apt  to  awake  out  of  a 
sleep  with  a  calm  mind,  remembering,  perhaps,  his  hallucination  as 
a  vivid  dream.  There  may  be  more  than  one  attack,  but  this  is  not 
common ;  and  the  duration  is  materially  abridged  by  opium  and  by 
the  employment  of  stimulants  and  nourishment.  The  form  of  de- 
lirium under  consideration  is  not  simply  a  sequel  of  defective  bram 
nutrition  in  fevers.  It  may  also  succeed  exhausting  discharges  and 
drains  from  the  system,  or  inability  to  obtain  or  to  digest  the  proper 
amount  of  food.  Thus,  it  may  happen  in  malignant  diseases  of  the 
stomach ;  also  in  mere  gastric  irritability  and  persistent  vomiting. 
The  most  marked  instance  of  this  kind  of  mental  wandering  I  have 
encountered  was  associated  with  functional  gastric  disorder,  which 
prevented  enough  food  from  being  retained.  In  this  patient  the  hal- 
lucination was  on  one  subject, — a  business  matter  which  had  been 
annoying  him  greatly  just  before  his  illness  became  decided. 

Delirium  is  at  times  simulated.     This  differs  from  real  delirium  by 


62  MEDICAL  DIAGNOSIS. 

ihe  absence  of  all  other  signs  of  illness,  and  by  the  sameness  of  the 
mental  wandering.  In  a  case  of  feigned  delirium  I  met  with,  the  man 
whined  when  spoken  to,  and  pretended  to  rave  ;  but  his  ideas  always 
ran  on  the  same  subject,  and  he  was  very  solicitous  about  his  food, 
and  about  other  matters  of  which  a  delirious  person  takes  no  notice. 
Delirium  is  more  or  less  continuous  ;  once  delirious,  a  patient  remains 
so  for  some  time,  and  until  the  exciting  cause  subsides.  In  this  re- 
spect hysterical  delirium  is  exceptional ;  it  does  not  last  long,  or  it 
intermits  and  then  reappears. 

Derangement  of  Consciousness. — This  may  be  of  any  grade, 
from  simple  clouding  to  complete  loss.  In  the  mildest  degree,  somno- 
lence, the  individual  has  an  appreciation  of  his  surroundings  and  can 
respond  when  addressed,  sometimes  intelligently. 

In  more  profound  impairment  of  consciousness,  sopor,  the  in- 
dividual lies  half  asleep  and  responds  but  sluggishly  to  sensory 
irritation,  although  he  can  be  readily  roused.  He  answers  in  mono- 
syllables ;  is  still  capable  of  limited  movement,  and  has  a  confused 
notion  of  his  surroundings.  Left  to  himself,  he  at  once  relapses  into 
sleep,  which  is  at  times  attended  with  mutterings. 

A  still  more  pronounced  degree  of  impairment  of  consciousness 
constitutes  the  phenomenon  called  stupor.  The  patient  lies  in  a  deep 
slumber,  from  which  he  cannot  be  roused  save  with  great  difficulty, 
and  when  roused  he  answers  reluctantly  and  briefly,  and  soon  re- 
sumes his  heavy  sleep.  The  expression  of  his  face  is  dull,  yet  now 
and  then  a  ray  of  intelligence,  excited  by  some  object  to  which  his 
attention  is  attracted  or  by  some  pleasant  reverie,  flits  across  his 
features.  Swallowing  is  possible,  and  the  reflexes  are  preserved, 
possibly  exaggerated.  Stupor  is  met  with  in  several  cerebral  affec- 
tions, and  after  an  epileptic  fit.  It  is  also  frequently  seen  in  typhoid 
fever,  or  as  the  result  of  narcotic  poisons.  But  there  is  nothing 
pathognomonic  about  it  in  these  various  conditions,  nothing  by  which 
we  can  judge  positively  of  its  origin. 

Coma  is  complete  loss  of  consciousness :  perception  and  volition 
are  alike  suspended,  and  there  is  an  appearance  of  the  profoundest 
sleep.  The  face  wears  a  confused  look ;  the  pupils  are  sluggish 
and  contracted  or  dilated ;  the  mouth  is  open,  the  tongue  dry.  All 
conscious  and  unconscious  response  to  sensory  irritation  is  lost. 
Shouting  or  shaking  will  not  arouse  the  individual.  The  extremities 
are  relaxed  and  the  reflexes  are  abolished.  Swallowing  is  impossible, 
and  the  sphincter  ani  is  no  longer  resistant.  The  breathing  may  be 
rhythmic,  but  it  is  frequently  irregular ;  at  times  it  is  retarded  and 
full,  at  other  times  of  Cheyne-Stokes  character :  towards  the  close  it 


DISEASES  OF  THE  BBAIN  AND  SPINAL   CORD.  63 

becomes  stertorous  and  stridulous.  Incontinence  of  urine  and  of 
faeces  develops. 

Coma  always  betokens  a  serious  disturbance  of  the  functions  of 
the  brain.  It  is  often  witnessed  in  cerebral  lesions,  as  from  pressure 
of  blood  or  fluid  in  brain-substance  or  in  ventricles,  more  rarely 
from  tumors,  abscesses,  or  thrombosis.  The  most  complete  coma  is 
seen  in  apoplexy ;  it  comes  on  cjuickly,  and  is  attended  with  noisy 
respiration  and  a  slow  pulse.  Another  form  of  coma,  scarcely  less 
complete,  is  caused  by  narcotic  poisoning ;  it,  however,  does  not  ap- 
pear suddenly,  and  when  from  opium  is  associated  with  contraction 
of  the  pupils.  Profound  intoxication  with  alcohol  induces  coma,  but 
the  attendant  symptoms,  as  a  rule,  make  the  association  clear.  The 
coma  of  fevers  and  of  acute  diseases,  whether  cerebral  or  not,  is  also 
gradually  produced,  but,  unlike  that  due  to  the  toxical  effect  of  opium, 
is  ordinarily  preceded  for  days  by  insomnia,  by  delirium,  and  by  other 
signs  of  cerebral  disturbance.  The  coma  of  epilepsy  is  recognized  by 
its  following  epileptic  seizures.  In  the  coma  of  Bright's  disease  the 
cause  is  made  manifest  by  finding  albumin  and  tube-casts  in  the 
urine,  and  by  the  evidences  of  preceding  uraemia.  Uraemic  coma 
may,  however,  come  on  suddenly  and  pass  off  suddenly.  It  is,  as 
a  general  rule,  associated  with  dilated  pupils.  Coma  also  sometimes 
occurs  in  connection  with  diabetes.  Under  such  circumstances  ex- 
amination of  the  urine  will  reveal  the  presence  of  sugar,  perhaps 
also  of  acetone  and  of  diacetic  acid. 

Sometimes  a  person  appears  to  be  comatose  when  his  intellect  is 
but  little  disordered.  He  may  be  paralyzed,  and  not  have  the  power 
to  communicate  his  ideas  from  crippled  articulation  or  aphasia.  This 
state  is  distinguished  from  coma  by  noting  that  the  patient's  attention 
is  always  directed  to  the  cjuestions  asked  him,  nay,  that  he  strives  to 
answer  them,  but  cannot ;  and  that  generally  he  has  lost  control  over 
the  muscular  movements  of  one  side  of  the  body.  Coma  must  not 
be  confused  with  syncope,  which  depends  upon  cerebral  anaemia,  is 
usually  of  brief  duration,  and,  except  feeble  heart  action,  is  unattended 
with  noteworthy  symptoms. 

Insomnia. — The  deprivation  of  sleep  is  a  concomitant  of  cerebral 
congestion  and  of  the  earlier  stages  of  cerebral  inflammation.  But  a 
person  may  be  sleepless  from  excessive  pain,  from  exhaustion,  from 
grief,  from  mental  excitement-  or  fatigue,  or  from  the  too  free  use  of 
coffee  or  of  tea ;  sometimes  insomnia  is  engendered  by  habitually 
working  late  at  night. 

Insomnia  often  precedes  or  attends  delirium,  as  appears  in  typhoid 
fever.     Among  purely  nervous  affections  it  is  most  marked  in  delirium 


64  MEDICAL  DIAGNOSIS. 

tremens.  It  is  a  very  troublesome  symptom ;  but,  occurring  in  so 
many  abnormal  conditions,  it  cannot  be  looked  upon  as  having  a 
distinct  and  specific  diagnostic  value, 

DERANGED   SENSATION. 

The  signs  of  perverted  or  impaired  sensation  are  numerous.  They 
may  be  either  due  to  an  alteration  of  the  general  sensibility  or  be  the 
signals  of  a  derangement  of  a  nerve  of  special  sense.  Let  us  look  at 
a  few. 

Hyperaesthesia. — An  exalted  sensilDility  of  surface  nerves — of 
those  of  the  skin,  the  mucous  membranes,  or  even  of  those  of  deeper- 
seated  structures — may  seem  to  be  due  to  inflammation.  We  may, 
as  a  rule,  distinguish  the  peripheral  sensitiveness  from  the  tenderness 
of  subjacent  inflammation .  by  its  extension  over  a  larger  surface  ; 
by  deep  pressure  producmg  no  more  pain  than  a  light  touch ;  by  the 
absence  of  signs  of  functional  disturbance  of  the  part  involved  ap- 
parently in  inflammatory  disease  ;  by  the  uniformity  of  the  pamful 
sensation,  no  matter  how  long  the  duration  of  the  disorder,  though 
the  sensitiveness  exhilDits  distinct  mtermissions  and  exacerbations. 

Hyperaesthesia  is  not  closely  connected  with  organic  diseases  of 
the  brain  or  of  the  spinal  cord.  Indeed,  it  is  in  them  not  common^ 
nor,  as  a  rule,  highly  developed.  By  far  the  most  usual  causes  of 
hyperesthesia  are  impoverished  blood  and  hysteria.  Sometmies 
hypersesthesia  is  produced  by  rheumatism  or  by  gout,  by  lithaemia,  or 
by  disturbance  of  the  function  of  the  kidney.  It  is  further  met  with 
in  epidemic  influenza ;  in  hydrophobia ;  in  inflammations  in  internal 
cavities  involving  the  ganglia  of  the  great  sympathetic ;  after  the  use 
of  ergot  and  of  opium ;  and  in  some  diseases  of  the  skin.  It  also 
attends  paroxysms  of  neuralgia,  as  witnessed  in  the  exquisite  sensi- 
tiveness of  the  skin  during  an  attack  of  tic  douloureux ;  the  painful 
spots,  too,  in  the  course  of  local  neuralgias  are,  when  not  the  result 
of  neuritis,  hypersesthetical.  Hyperaesthesia  attends  the  irritative 
stage  of  inflammation  of  sensory  nerves  from  whatever  cause. 

The  seat  of  the  heightened  sensibility  is  ordinarily  in  the  skin,  in 
the  distribution  of  the  cutaneous  nerves.  Yet  hypera?sthesia  may 
affect  the  nerves  of  the  special  senses,  manifesting  itself,  for  instance, 
by  intolerance  of  light  or  of  sound.  But  this  variety  of  hyperaesthesia 
need  here  be  but  alluded  to,  as  we  shall  presently  look  more  fully  at 
the  signs  of  disturbance  of  these  nerves.  The  increased  sensitiveness 
may  depend  on  irritation  of  the  peripheral  nerves,  or  of  a  cerebral 
centre,  or  of  the  conducting  fibres  of  the  spinal  cord,  especially  of 
those  of  the  posterior   columns.     Hyperaesthcsia  is   often  conjoined 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  65 

to  perverted  sensation,  and  not  a  mere  increase.  When  a  painful 
sensation  is  more  acutely  felt  than  normal,  it  is  called  hyj^eralgesia. 
Sensibility  to  pain  is  most  readily  tested  by  a  pinch  or  a  prick,  or  by 
a  wire  brush  with  a  faradic  current. 

Let  us  now  look  at  hypersesthesia  in  connection  with  affections  of 
the  nervous  system,  especially  with  those  of  the  brain  and  cord. 

Hypercesthesia  is  general  and  combined  with  signs  of  organic  disease. 
— We  find  this  in  tumors  pressing  upon  the  pons  Varolii  and  corpora 
quadrigemina,  or  in  alterations  or  injuries  of  the  posterior  columns 
of  the  cord  and  those  producing  irritation  in  the  course  of  the  con- 
ducting fibres,  in  some  cases  of  cerebral  meningitis,  and  in  spinal 
meningitis  in  which  the  posterior  nerve-roots  are  implicated.  We 
have  in  all  these  conditions  a  hypersesthesia  more  or  less  extensive, 
and  often  combined  with  hyperalgesia  and  with  pain.  In  making  up 
our  minds  as  to  the  cause  of  the  extended  hypersesthesia,  the  sensi- 
tiveness in  diffuse  neuritis,  in  general  neuralgias,  and  in  reflected  irri- 
tation to  the  posterior  columns,  especially  in  hysterical  subjects,  must 
always  be  remembered. 

Hypercesthesia  is  limited  to  one  side. — Limited  hypersesthesia  be- 
longs much  more  closely  to  spinal  than  to  cerebral  disease.  We  also 
find  it  in  connection  with  special  neuralgias,  and  the  sensitive  skin 
shows  augmented  electrical  sensibility.  In  some  instances  of  limited 
as  well  as  of  more  extended  hypersesthesia  nothing  abnormal  can  be 
detected,  and  the  disorder  must  be,  with  our  present  knowledge,  set 
down  as  a  neurosis,  one  concerning  which  it  remains  uncertain  whether 
it  be  of  central  or  of  peripheral  origin. 

Anaesthesia. — Loss  of  sensation,  or  ansesthesia,  is  of  various  de- 
grees. It  may  be  complete  or  partial, — a  perfect  absence  of  sensibility 
or  its  mere  benumbing.  It  may  be  of  cerebral,  of  spinal,  or  of  periph- 
eral origin.  It  may  involve  only  common  tactile  sensibility,  or  in 
varying  combination  and  degree  also  the  sense  of  pain,  the  muscular 
sense,  the  temperature  sense,  and  stereognostic  sense.  In  the  parts 
affected  with  ansesthesia  the  nutrition  is  less  active,  the  temperature 
is  diminished,  and  there  is  a  feeling  of  numbness.  Frequently  the 
circulation  in  the  skin  is  retarded,  occasioning  a  perceptible  lividity 
and  discoloration  of  the  surface ;  or  there  are  coexisting  trophic 
changes,  such  as  glazing  of  the  skin  and  grayness  of  the  hair.  The 
electrical  sensibility  is  diminished,  and  is  made  very  manifest  by  the  use 
of  the  wire  brush  with  either  the  faradic  or  the  galvanic  current.  In 
hysterical  ansesthesia  this  is  a  particularly  striking  feature. 

Loss  of  sensation  has  a  much  more  constant  connection  vdth 
organic  affections  of  the  nervous  centres  than  increased  sensibility, 


66  MEDICAL  DIAGNOSIS. 

which,  however,  may  precede  it.  In  the  insane,  especiahy  in  mono- 
maniacs, aneesthesia  is  common,  and  ordinarily  very  extended :  so, 
too,  in  general  paralysis.  Indeed,  with  few  exceptions,  an  extended 
anaesthesia  points  to  an  affection  of  the  nen^ous  centres.  It  may  in 
these  organic  cases  be  both  general  and  verj^  complete.^  Localized 
anaesthesia  may  be  an  early  sign  of  degenerative  change,  and  precede 
for  a  long  time  an  attack  of  apoplexy  with  arteriosclerosis. 

If  the  defective  sensibility  be  owing  to  a  spinal  malady,  it  is  gen- 
erally found  in  the  lower  extremities,  and  coexists  with  paralysis. 
Anfesthesia  of  spinal  origin  is  usually  inchcative  of  the  sensory  con- 
ducting paths  in  the  posterior  columns  having  been  disturbed  or 
altered :  when  about  the  body,  as  in  transverse  dorsal  myelitis,  there 
is  mostly  a  zone  of  hyperaesthesia  above  the  zone  of  aucesthesia.  A 
limited  area  of  anaesthesia,  Allen  Starr-  has  demonstrated,  is  caused 
by  a  limited  lesion  in  the  spinal  cord,  and  the  situation  and  shape 
of  the  area  of  anaesthesia  tell  us  the  level  of  the  lesion.  In 
hysterical  paraplegia,  in  paraplegia  from  hypnotic  suggestion,  or  that 
following  railroad  or  other  injuries,  the  line  of  lost  sensibility  is,  as 
Charcot^  has  shown,  very  significant :  it  excludes  the  genital  organs. 

In  accordance  with  the  Avell-known  law  of  the  decussation  of 
sensitive  impressions  in  the  cord,  disease,  if  only  of  one  posterior  half, 
is  followed  by  lost  sensation  on  the  opposite  side  of  the  body.  One- 
sided anaesthesia,  affecting  even  the  face  up  to  the  middle  line,  is 
sometunes  met  with  in  hysterical  subjects  or  after  typhoid  fever.* 
Hysterical  hemianaesthesia  is  generally  on  the  left  side.  But  strictly 
limited  one-sided  anaesthesia  is  more  apt  to  be  found  in  a  distinct 
brain  lesion,  and  the  particular  affection  occasioning  the  hemiances- 
thesia  is  disease  of  the  white  substance  just  outside  of  the  optic 
thalamus,  of  the  posterior  part  of  the  internal  capsule,  on  the  side 
of  the  brain  opposite  to  the  side  of  the  body  which  shows  the  anaes- 
thesia, or  damage  to  the  fibres  which  conduct  sensation  through  the 
pons  or  the  crus.  A  lesion  involving  the  upper  part  of  the  pons  may 
give  rise  to  "  crossed  anaesthesia," — namely,  loss  of  sensibility  upon 
the  same  side  of  the  face  and  upon  the  opposite  side  of  the  body. 
Hemianaesthesia  is  a  not  uncommon  symptom  between  the  attacks 
of  hystero-epUepsy. 

A  localized  form  of  anaesthesia  happens  now  and  then  in  conse- 
quence  of  an   affection  of  the  fifth   nerve.     The    extent  of  loss    of 

^  As  in  a  case  reported  by  Winter,  quoted  in  Schmidt's  Jahrbuch,  1883,  No.  1. 

^  Amer.  Journ.  Med.  Sci.,  July,  1892. 

^  (Euvres  completes,  iii. 

*  Calmet,  Bulletin  de  la  Societe  Medicale  des  Hopitaux,  1876. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  67 

sensation  depends  much  upon  the  part  of  the  nerve  at  which  the 
cause  of  disturbance  is  seated.  The  skin  of  the  nose  and  cheek  may 
become  devoid  of  sensation ;  the  reflex  movements  of  the  muscles 
of  the  face  may  cease  ;  the  conjunctiva,  or  the  whole  surface  of  the 
eye,  or  one-half  of  the  toiigue,  may  be  deprived  of  sensibility.  Only 
one  of  these  phenomena,  or  all  conjointly,  may  be  encountered,  ac- 
corchng  as  part  of  one,  or  one,  or  all  of  the  branches  of  the  fifth 
nerve  are  affected.  Sometimes,  as  Romberg  proves,  trigeminal  ances- 
thesia  is  of  rheumatic  origin.  When  it  is  complicated  with  disturbed 
functions  of  adjoining  cerebral  nerves,  it  may  be  assumed  that  the 
cause  is  seated  at  the  base  of  the  brain. 

Anaesthesia  is  stated  to  be  sometimes  the  result  of  reflex  action. 
It  may  thus  arise  in  disorders  of  any  of  the  viscera,  and  from  an  irri- 
tation of  any  sensitive  nerve.  It  has,  for  instance,  been  observed  in 
both  lower  limbs  in  sciatica.  But  in  nearly  all  of  these  instances  of 
supposed  reflected  nerve  irritation  there  is  really  a  neuritis. 

Diminished  or  lost  sensibility  to  touch  generally  goes  hand  in  hand 
with  diminished  or  lost  sensibility  to  pain,  but  the  sensibility  to  pain 
may  be  augmented.  This  "  auEesthesia  dolorosa"  is  most  commonly 
met  with  in  multiple  neuritis,  and  in  spinal  meningitis  and  myelitis 
from  pressure. 

Very  often  numbness  and  other  altered  sensations  are  complained 
of,  and  yet  the  wl'j^ole  is  subjective  ;  when  tested,  anaesthesia  is  not 
found.  In  endeavoring,  indeed,  to  form  an  opinion  of  the  existence  or 
the  completeness  of  anaesthesia,  we  do  not  trust  to  the  patient's  state- 
ments. We  touch  the  part  lightly  Avith  the  finger  or  a  feather  while 
his  eyes  are  shut,  and  the  skin  is  pinched  or  a  pin  used  to  ascertain 
the  extent  of  the  impaired  sensation.  Or  w^e  resort  to  means  by 
which  we  can  make  accurate  comparisons  ;  and  one  of  the  best  is  to 
pursue  the  method  employed  by  Weber,  which  consists  in  determining 
how  closely  the  points  of  a  pair  of  compasses  sheathed  with  cork  may 
be  approximated  on  the  skin  and  yet  be  felt  as  two  distinct  points. 
An  instrument  for  the  same  purpose,  called  the  "  aesthesiometer," 
was  invented  by  Sieveking  (Fig.  11),  and  is  very  much  the  same  as  the 
lighter  one  of  Brown-Sequard  now  in  common  use.  An  instrument 
combining  the  principle  of  the  beam  compass  with  that  of  the  mathe- 
matical one  has  been  contrived  by  Ogle,  and  one  with  ivory  points, 
by  Manouvriez.  In  Carroll's  aesthesiometer  each  arm  is  bifurcated, 
having  one  blunt  and  one  sharp  end,  thus  enabling  us  to  test  pain 
as  well  as  touch.  The  points  of  the  aesthesiometer,  whether  blunted 
or  sharp,  should  be  put  down  lightly  and  simultaneously,  and  parallel 
with  the  direction  of  the  cutaneous  nerves  ;  at  all  events,  the  same 


68 


MEDICAL  DIAGNOSIS. 


relative  direction  should  be  preserved  in  making  comparative  esti- 
mates. 

To  understand  any  results  obtained  regarding  the  tactile  sense,  it 
is  necessary  that  we  should  be  aware  how  this  differs  in  some  parts 
of  the  body.  Most  works  on  physiology  contain  an  account  of  the 
researches  of  Weber  and  of  those  who  have  prosecuted  the  inquiry 
he  started ;  yet  a  few  of  the  conclusions  may  be  here  mentioned.     At 


Fig.  11. 


The  Besthesiometer  of  Sieveking. 


the  tip  of  the  tongue  two  points  can  be  readUy  distinguished  when 
separate  from  each  other  -^  of  an  inch,  or  half  a  Paris  line,  one  and 
a  half  millimetres ;  at  the  palmar  surface  of  the  third  phalanx  the 
limit  is  one  line  ;  on  the  palmar  surface  of  the  second  phalanx,  two 
lines,  the  same  on  the  red  surface  of  the  lips ;  on  the  palm  of  the 
hand,  the  cheek,  and  the  extremity  of  the  great  toe,  five  lines  ;  on  the 
back  of  the  hand,  at  the  knuckles,  eight  lines  ;  at  the  lower  part  of 
the  forehead,  ten  lines  ;  on  the  skin  over  the  patella  and  the  dorsum 
of  the  foot,  eighteen  lines  ;  over  the  middle  of  the  arm,  the  tliigh, 
and  over  the  spine,  thirty  lines  ;  on  the  back,  sixty  millimetres  is 
common.  But  these  observations  are  found  to  vary  somewhat  even 
in  healthy  persons,  some  being  able  to  distinguish  at  a  shorter  dis- 
tance than  others. 

Besides  the  impairment  or  loss  of  tactile  discrimination,  the  altered 
sensibility  may  show  itself  in  the  loss  of  the  faculty  of  feeling  pinch- 
ing, pricking,  and  other  acts  which  excite  pain,  "  analgesia  f  or  in 
insensibility  to  tickling ;  or  in  the  want  of  appreciation  of  heat  or 
cold,  "  altered  temperature  sensibility ;"  or  in  the  loss  of  the  sen- 
sation which  attends  muscular  contraction,  whether  produced  by 
the  will  or  by  an  electrical  current.  Now,  it  is  in  individual  cases 
always  of  importance  to  note  which  particular  kind  of  sensibility  is 
affected. 


DISEASES  OF  THE  BRAIN  AND   SPINAL   CORD. 


69 


Fig.  12. 


In  sclerosis  of  the  cord  the  sensation  is  retarded  rather  than  lost,^ 
A  form  of  perverted  sensibility,  which  may  or  may  not  be  associated 
with  anaesthesia,  consists  in  the  sensibility  being  more  or  less  perfect, 
while  there  is  doubt  as  to  the  side  touched ;  indeed,  the  touch  is 
commonly  felt  at  a  corresponding  part  of 
the  other  limb.  This  cdlochiria^  is  gen- 
erally  found  in  association  with  organic 
spinal  disease  ;  but  it  may  also  manifest 
itself  in  hysteria.  A  sufficient  explana- 
tion of  the  erroneous  reference  of  impres- 
sions is  wanting.  In  a  case  recorded  by 
Ferrier  ^  the  reversal  showed  itself  also  in 
the  reflex  reactions.  Tickling  the  sole  of 
one  foot  caused  retraction  of  the  other ; 
tickling  the  inside  of  one  thigh  produced 
flexion  of  the  other.  Occasionally  a  single 
sensory  impression  is  perceived  as  two  or 
more ;  this  is  known  as  "  polysesthesia," 
and  is  most  often  met  with  in  locomotor 
ataxia. 

Sensibility  to  temperature  has  a  close 
connection  with  sensibility  to  pain ;  but 
not  always.  There  may  be  crossed  pa- 
ralysis of  the  thermal  sense,  while  other 
senses  are  undisturbed.'^  Sometimes  the 
temperature  sense  is  exaggerated  or  dimin- 
ished, or  much  perverted,  and  cold  objects 
feel  hot,  and  the  reverse.  Then  points 
may  be  found  in  the  skin  where  only 
cold,  others  where  only  heat,  is  appre- 
ciated. To  test  heat,  a  heated  spoon  or 
•a  test-tube  filled  with  hot  water  is  the 

readiest  means  ;  to  test  cold  a  sponge  that  has  been  dipped  in  cold 
water  or  a  piece  of  ice  is  best. 

Muscular  ancesthesia  has  been  mentioned.  It  is  closely  connected 
with  the  power  we  possess  of  estimating  weight,  the  "  muscular 
sense ;"  and  the  loss  of  ability-  to  perceive  differences  in  smah 
weights,  or  the  impairment  of  the  sense  of  muscular  movement  and 
effort,  is  its  most  common  form.     It  is  really  distinct  from  the  sensi- 

^  Vulpian,  Archives  de  Physiologie,  t.  i.,  No.  3. 

2  Obersteiner,  Brain,  July,  1881.  ^  Brain,  October,  1882. 

*  Case  reported  by  Weir  Mitchell,  Trans.  Assoc.  Amer.  Phys.,  vol.  vii.,  1892. 

5 


Carroll's  sesthesiometer. 


70  MEDICAL   DIAGNOSIS. 

tiveness  of  the  muscles  to  pressure  or  to  electrical  stimulation,  which 
may  be  also  wholly  wanting.  The  loss  of  the  power  of  appreciating 
muscular  contraction,  as  well  as  the  deficiency  of  sensation,  is  most 
readily  tested  by  the  use  of  the  faradic  current ;  the  contraction  of  the 
muscles  produces  no  feeling. 

Muscular  anaesthesia  is  frequently  combined  with  inability  to  de- 
termine the  posture  of  a  limb  when  the  eyes  are  closed  ;  it  may  or  may 
not  be  associated  with  cutaneous  ansesthesia.  It  is  not  uncommon 
in  hysteria  and  in  locomotor  ataxia.  Here  the  loss  of  the  apprecia- 
tion of  the  position  of  the  limbs  and  of  the  sense  of  muscular  effort 
is  the  usual  variety.  When  the  muscles  are  completely  paralyzed, 
the  muscular  sense  cannot  be  tested.  The  muscular  sense  has  been 
localized  by  Allen  Starr  and  McCosh  at  the  junction  of  the  superior 
and  inferior  parietal  convolutions,  behind  the  posterior  central  con- 
volution.^ In  testing  for  the  muscular  sense,  the  eyes  of  the  person  on 
whom  the  test  is  made  should  be  kept  closed,  and  objects  used 
should  be  of  uniform  size.  To  detect  the  difference  in  weight,  and 
thus  the  resistance  to  contraction,  Gowers  ^  recommends  leather  balls 
containing  weights  from  two  drachms  to  two  pounds.  The  weights 
are  placed  in  a  bag,  suspended  by  a  string  to  the  parts  to  be  tested. 

The  recognition  of  objects  by  the  sense  of  touch,  stereognosis,  is 
not  rarely  impaired  by  lesions  of  the  cortex,  especially  in  the  central 
and  parietal  regions. 

Parsesthesia. — This  is  a  perversion  of  sensation,  not  an  exal- 
tation. It  does  not  disclose  itself  by  pain  and  tenderness,  but  by 
itching,  by  formication,  by  unnatural  feelings  of  various  kinds,  such  as 
the  feeling  of  tingling,  of  pins  and  needles,  of  goose-flesh,  of  thrill- 
ing, of  flushing,  of  the  trickling  of  cold  water,  of  shock-like  sensa- 
tions, or  of  a  sense  of  tightness,  as  in  the  girdle  pain.  It  is  generally 
purely  subjective,  though  it  may  be  influenced  by  touch.  A  form  of 
parsesthesia  is  aeroparcesthesia.  This  is  chiefly  characterized  by 
numbness  of  the  extremities.  It  is  encountered  in  women  at  the 
menopause,  and  in  those  who  do  washing,  scrubbing,  or  sewing.  It 
may  be  also  found  in  men,  and  by  some  is  believed  to  be  a  neurosis, 
by  others  a  neuritis.^ 

The  alterations  of  sensibility  discussed  manifest  themselves  chiefly 
in  connection  with  external  impressions.  Let  us  now  look  at  some 
abnormal  sensations  which  are  not  objective,  but  subjective, — arising 

ijAmer.  Journ.  Med.  Sci.,  Nov.  1894. 

'^  Diseases  of  the  Nervous  System,  vol.  i.,  2d  ed.,  1893. 

^  Sinkler,  Medical  News,  Aug.  1894,  p.  178. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  71 

independently  of  external  impressions.     Headache  and  vertigo  are  of 
this  character. 

Headache. — In  every  case  of  headache  we  must  first  ascertain 
that  the  pain  really  originates  within  the  cranium,  and  that  it  is  not 
owing  to  supraorbital  neuralgia ;  to  rheumatism  of  the  scalp  ;  to  dis- 
ease of  the  bones  ;  to  periostitis,  syphilitic  or  otherwise  ;  or  to  affec- 
tions of  the  ear.  To  accomplish  this  is  generally  not  difficult.  An 
inquiry  into  the  history  of  the  case,  the  locality  of  the  pain,  and  its 
augmentation  on  pressure  in  most  of  the  disorders  named,  furnish 
evidence  whicli  decides  the  source  of  the  cephalalgia  to  be  external 
to  the  cranium. 

Another  possible  cause  of  headache,  always  to  be  kept  in  mind, 
has  been  made  clear  by  the  labors  of  eye-surgeons.  It  occurs  in 
persons  who  have  headache  more  or  less  intense,  with  abnormal  sen- 
sations in  the  skin  of  the  scalp,  and  at  times  vertigo  and  spasm  of 
the  eyelids  and  occipito-frontal  muscle.  The  near  use  of  their  eyes 
increases  their  distress.  When  the  eye  is  carefully  examined,  an 
optical  defect  is  found,  especially  hyperopia  or  astigmatism.  Again, 
we  may  have  defective  vision,  with  sleeplessness  and  severe  headache, 
dependent  on  decayed  teeth,  and  disappearing  with  their  removal.^ 

Having  settled  that  none  of  these  conditions  are  present,  we  have 
to  determine  the  probable  cause  of  the  headache, — a  question  the 
solution  of  which  depends  frequently  more  upon  the  symptoms  attend- 
ing the  pain  than  upon  its  character.  But  let  us  glance  at  some  of  the 
common  causes  and  characteristics  of  intracranial  headache. 

Headache  is  a  rarely  absent  symptom  of  disease  of  the  brain.  In 
acute  inflammation  it  is  generally  agonizing,  and,  while  subject  to 
exacerbations,  continuous  ;  it  is  associated  with  fever,  with  vomiting, 
and  with  delirium.  In  abscesses  of  the  brain,  in  softening,  and  in 
similar  affections  which  run  a  chronic  course,  the  headache  is  less 
violent,  and  only  occasionally  paroxysmal ;  it  is  usuahy  accompanied 
by  signs  of  disturbed  intellection  and  of  deranged  motion.  In  tumor 
of  the  brain  the  headache  is  apt  to  be  severe  and  paroxysmal,  but 
intellection  is  not  at  first  much  affected.  In  congestion  of  the  brain 
the  pain  is  dull,  increased  by  stooping  or  lying  down,  by  long  sleep, 
and  by  bodily  or  mental  fatigue  ;  its  concomitants  are  a  flushed  face, 
a  throbbing  of  the  arteries  of  the  neck,  an  eye-ground  in  which  the 
vessels,  especially  the  veins,  are  turgid,  and  a  heated  head,  with  in- 
creased temperature,  as  shown  by  the  surface  thermometer.  A  form 
of  congestive  lieadache,  apt  to  be  relieved  by  bleeding  at  the  nose,  is 

^  Case  reported  by  Ogle,  Medical  Times  and  Gazette,  Aug.  1872. 


72  MEDICAL  DIAGNOSIS. 

often  seen  in  young  people  at  the  age  of  puberty :  the  attacks  are 
brought  on  by  running  or  other  violent  exercise.  In  diseases  of  the 
meninges,  especially  those  of  a  chronic  character,  the  pain  is  constant 
and  fixed,  and  sometimes  very  sharp.  The  latter  kind  of  pain  when 
persistent  is  also  significant  of  disease  of  the  superficial  brain  struc- 
tures in  contact  with  the  meninges,  and  is  usually  felt  at  the  place  on 
the  head  which  corresponds  to  the  seat  of  the  lesion  within  the  skull. 

Nervous  or  neuralgic  headache  is  most  common  in  women,  espe- 
cially in  angemic  women.  It  is  unremitting  and  very  severe,  yet  of 
short  duration ;  but  after  it  is  over  there  is  great  lassitude,  and  even 
some  local  soreness.  It  is  not  attended  with  rise  of  temperature,  or 
with  any  signs  of  disturbance  of  the  brain,  except  at  times  with  a 
confusion  of  vision  and  an  inability  to  carry  on  a  connected  train  of 
thought.  Anything  that  agitates  the  nervous  system  produces  an 
attack ;  stimulants  and  food  often  relieve  it.  To  the  class  of  head- 
ache under  consideration  may  be  referred  many  cases  of  migraine. 

But  migraine,  megrim,  sick  headache,  or  hemicrania,  has  certain 
symptoms  which  set  it  apart.  The  pain  is  usually  attended  with 
nausea  and  vomiting,  is  generally  at  first  one-sided,  and  is  accompa- 
nied, or  more  often  preceded,  by  visual  disorder,  such  as  a  bright  spot 
gradually  enlarging.  The  disturbance  of  vision  begins  suddenly,  last- 
ing perhaps  for  half  an  hour  before  the  headache  begins,  and  is  at  times 
associated  with  tingling  on  one  side,  with  difficulty  in  speech  and  con- 
fusion of  ideas ;  sometimes  there  is  disturbance  of  hearing.  The 
headache  often  begins  in  the  temple,  and  is  very  severe ;  it  spreads 
over  the  head,  it  may  extend  to  the  neck,  or  may  leave  the  side 
originally  affected  to  become  agonizing  on  the  other.  There  may  be 
soreness  of  the  head  with  the  pain,  and  there  is  often  pallor  of  the 
face,  and  a  contraction  of  one  pupil.  Coldness  of  the  extremities  is 
not  uncommon,  and  the  patient  vomits  bile.  This  bilious  vomiting 
often  terminates  the  attack,  which  comes  on  only  in  paroxysms.  Mi- 
graine is  frec^uently  met  with  in  gouty  or  lithsemic  persons,  and  the 
urine  is  of  high  specific  gravity,  and  contains  an  excess  of  uric  acid 
and  urates,  though,  during  the  attack  itself,  no  such  increase  may  be 
met  with.  It  is  sometimes  excited  by  reflex  influences  such  as  eye- 
strain, nasal  or  pharyngeal  disease,  dental  caries,  gastric  disturbance, 
or  uterine  or  menstrual  derangement. 

Sympathetic  headache  is  found  mainly  in  connection  with  disorders 
of  the  uterus  and  of  the  alimentary  tube,  and  is  often  worse  in  the 
morning,  before  food  has  been  taken. 

Headache  may  be  dependent  upon  various  poisons,  whether  gen- 
erated in  the  system  or  introduced  from  without ;   for  instance,  in 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  73 

diseases  of  the  kidney  the  retention  of  a  large  quantity  of  urea  in 
the  blood  becomes  the  cause  of  persistent  pain  in  the  head.  In 
torpidity  of  the  liver,  in  lead  poisoning,  in  opium  eaters,  in  drunk- 
ards, after  the  use  of  strychnine  or  of  large  quantities  of  quinine, 
headache  is  common ;  and  it  is  very  likely  that  in  persons  with  faulty 
assimilation  certain  ptomaines  give  rise  to  headache. 

In  studying  headache  as  a  symptom,  we  must  always  note  what 
influence  position  and  movements  of  the  head,  and  percussion  and 
palpation,  have  on  the  pain :  whether,  for  instance,  stooping,  swing- 
ing the  head  from  side  to  side,  or  rising  rapidly  from  the  horizontal 
to  the  erect  posture  affect  it,  and  cause  it  to  be  combined  with  ver- 
tiginous or  other  abnormal  sensations.  In  headache  connected  with 
organic  disease  of  the  brain  the  pain  is  increased  by  whatever  in- 
creases the  blood-pressure, — by  stooping,  by  coughing,  by  any  effort. 
The  site  of  pain  bears  no  definite  relation  to  the  site  of  lesion,  except 
the  lesion  be  near  the  surface.  With  severe  paroxysms  of  pain 
vomiting  often  occurs.  Headache  increased  by  the  erect  posture  and 
relieved  by  lying  down  bespeaks  an  anaemic  condition  of  the  brain. 

Vertigo. — This  is  a  transitory  feeling  of  swimming  of  the  head, 
a  sense  of  falling,  or  illusory  movements  of  external  objects.  The 
sensation  is  apt  to  occur  whenever  the  circulation  within  the  cranium 
is  disturbed,  and  is  often  symptomatic  of  a  disease  of  the  heart,  liver, 
kidneys,  or  of  an  affection  of  the  stomach,  or  of  gout  or  lithsemia ; 
or  it  accompanies  anaemia,  or  follows  exhausting  discharges.  In  the 
defective  blood-supply  to  the  brain,  produced  by  arteriosclerosis,  the 
vertigo,  often  very  severe,  is  attended  by  signs  of  the  morbid  process 
in  other  parts  of  the  body,  and  the  tense  pulse,  increased  blood-press- 
ure, and  accentuated  second  sound  of  the  heart  explain  the  cause  of 
the  giddiness.  Extreme  slowness  of  pulse,  and  a  sensation  of  falling 
in  a  given  direction,  as  in  Meniere's  disease,  are  not  infrequent.^ 

Vertigo  may  attend  any  disorder  of  the  brain.  The  cerebral  form 
is  recognized  in  part  by  the  absence  of  those  affections  of  other 
organs  which  would  induce  the  dizziness, — and  among  these  we  must 
not  forget  eye-strain,  and  local  palsies  of  the  muscles  of  the  eyeball, 
in  part  by  its  being  joined  to  an  almost  constantly  present  sense  of 
uncertainty  in  movement,  to  headache,  and  to  further  signs  of  an  en^ 
cephalic  malady.  Moreover,  it"  is  usually  objective  in  character: 
surrounding  objects  appear  to  the  patient  to  move,  not  he  himself; 
and,  unlike  the  subjective  vertigo  so  common  in  mere  sympathetic 
disturbance  of  the  brain,  closing  the  eyes  relieves  it. 

^Grasset,  Vertige  Cardio  vasculaire,  Paris,  1890  ;  Church,  Medical  News,  June, 
1892. 


74  MEDICAL  DIAGNOSIS. 

The  most  common  form  of  vertigo,  not  arising  from  brain  affec- 
tion, is  the  so-called  stomachal  vertigo.  It  is  apt  to  come  on  in 
paroxysms,  sometimes  in  the  middle  of  the  night  or  in  the  early 
morning,  and  is  associated  with  a  dull,  heavy  ache  in  the  head,  and 
with  more  or  less  gastric  disturbance,  often  following  indiscretion  in 
diet.  Yet  the  tongue  may  be  clean,  and  the  digestive  disorder  so  slight 
that  it  is  only  by  the  after-symptoms,  by  the  relief  afforded  by  at- 
tention to  diet,  and  by  remedies  acting  on  the  digestion,  that  we 
clearly  make  out  the  cause  of  the  vertigo.  Between  the  attacks  the 
patient  is  free  from  the  affection ;  though  there  are  cases  of  more 
chronic  kind,  in  which  a  certain  amount  of  giddiness  is  present  for 
long  periods  with  only  comparatively  short  intervals  of  freedom. 
The  giddiness  may  become  aggravated  into  a  severe  attack  if  the 
stomach  be  for  a  long  time  empty.  In  gastric  vertigo  there  is  no 
loss  of  consciousness.  The  pathology  is  obscure.  Woakes^  has 
endeavored  to  establish  a  direct  nervous  communication  between  the 
stomach  and  the  labyrinth  to  explain  the  vertigo.  Others  regard  the 
irregularity  in  the  cerebral  circulation  produced  by  the  gastric  dis- 
order, anaemia  or  hypersemia,  as  the  cause. 

Very  similar  to  gastric  vertigo  is  the  vertigo  of  malassimilation  in 

'  connection  with  lithoemia.     The  history  of  the  case,  the  state  of  the 

urine,  the  striking  change  which  follows  diet  and  treatment  that  alter 

the  formation  and  elimination  of  uric  acid,  distinguish  lithsemic  vertigo. 

Another  form  of  vertigo  of  eccentric  origin  is  that  associated  with 
partial  deafness  or  ringing  in  the  ears.  Again,  there  may  be  an 
affection  of  the  internal  ear,  the  semicircular  canals  of  the  labyrinth 
especially  being  the  seat  of  an  inflammation,  and  the  vertigo  set  in 
suddenly.  Its  onset  is  apt  to  be  associated  with  vomiting,  with  sud- 
denly developed  tinnitus,  with  pain  produced  in  the  affected  ear  by 
the  slightest  noise,  and  with  symptoms  of  apoplexy  or  a  fainting  con- 
dition. Such  cases,  to  which  Meniere  particularly  has  called  atten- 
tion, may  very  speedily  terminate  fatally.  But  the  acute  seizure, 
which  is  by  far  the  most  common  beginning  of  the  aural  vertigo,  may 
leave  behind  giddiness  and  a  persistent  unsteadiness  in  standing  and 
walking,  or  a  tendency  to  go  forward  or  backward,  or  a  reeling  gait. 
These,  with  the  intense  vertigo  and  the  vomiting,  the  persistent  noises 
in  the  ears,  the  unimpaired  consciousness,  and  the  deafness,  be- 
come valuable  signs  of  Meniere's  disease.  The  deafness  shows  espe- 
cially in  defect  of  power  of  hearing  vibration  conducted  through  the 
skull.     It  is  often  one-sided,  generally  on  the  side  of  the  marked  tin- 


^ Deafness,  Giddiness,  etc.,  1879. 


DISEASES  OF  THE  BRAIN   AND  SPINAL   CORD.  75 

nitus,  and  never  absolute.  Again,  it  may  be  noticed  that  there  is 
deafness  for  certain  groups  of  musical  sounds,  which  Knapp  accepts 
as  proof  that  the  disorder  has  extended  to  the  cochlea. 

In  some  instances  the  patient  has  a  tendency  to  turn  to  one  side 
or  to  walk  round  and  round  in  a  circle  ;  and  he  is  always  miserable, 
although  his  general  health  suffers  but  little.  The  disturbance  of  the 
equilibrium  is  not  always  present ;  there  may  be  disturbance  of  hear- 
ing without  it.  The  vertigo  is  generally  the  most  prominent  symptom 
of  the  disease,  and  persistent  vertigo  not  epileptic  in  character  or 
obviously  associated  with  an  organic  brain  affection  is  nearly  always 
aural.  The  dizziness  is  very  apt  to  be  severe,  to  come  on  in  parox- 
ysms, and  to  be  excited  by  some  effort  or  movement.  It  becomes 
associated  with  pallor,  with  faintness,  with  vomiting,  and  in  part  it 
remains  even  between  the  paroxysms.  During  these  the  roaring  in 
the  ears  may  or  may  not  be  increased,  but  signs  of  eye-disturbance 
are  very  apt  to  show  themselves.  The  disease  may  result  from  any 
process  that  involves  the  labyrinth  and  the  nerve-endings.  It  is  more 
common  in  men  than  in  women,  and  is  very  rare  in  young  persons. 
It  may  come  on  after  cold  and  exposure,  or  originate  in  gout  or  in 
syphilis.  It  has  also  been  observed  in  men  working  under  ground 
and  breathing  compressed  air.^  All  cases  of  aural  vertigo  do  not  set 
in  suddenly  ;  some  are  slight,  others  are  very  severe  and  do  not  cease 
until  the  hearing  is  totally  lost.  Many  cases  progress  slowly  to  re- 
covery. Aural  vertigo  in  its  milder  forms  may  be  met  with  in  affec- 
tions of  the  ear  that  have  had  their  origin  in  catarrhal  inflammation 
travelling  along  the  Eustachian  tube. 

A  peculiar  variety  of  paroxysmal  vertigo  has  been  observed  in 
Switzerland,  France,  and  Japan,  associated  with  weakness  of  the 
extremities,  drooping  of  the  eyelids,  and  mental  depression,  but  with 
preservation  of  consciousness.  These  attacks  may  occur  very  fre- 
quently or  be  months  apart.  They  have  been  described  by  Gerlier, 
and  the  disease  is  known  by  his  name,  or  as  paralyzing  vertigo. 
Toxaemia  has  been  suggested  as  the  probable  cause. 

To  return  to  vertigo  connected  with  cerebral  or  cerebro-spinal 
disease.  There  is  a  kind  which  Trousseau  especially  has  described. 
The  abnormal  sensation  is  very  short  in  its  duration,  but  severe ;  the 
patient  momentarily  loses  all  consciousness.  The  vertigo  recurs  at 
uncertain  times :  while  actively  engaged,  sometimes  while  in  bed  and 
half  asleep.  The  head  feels  heavy  after  an  attack,  and  the  mind  is 
temporarily  stupefied ;   otherwise  the  health  is  good.     This  type  of 


1  Curnow,  Lancet,  1894,  No.  3715,  p.  1088. 


76  MEDICAL   DIAGNOSIS. 

vertigo  is  dangerous.  It  is  often  the  precursor  of  ejnlepsy^  and  after  a 
time  becomes  associated  with  convulsions. 

Another  kind  of  vertigo  is  that  wliich  arises  from  overioorh  of  the 
brain,  very  likely  connected  with  temporary  hyperaemia.  At  times 
giddiness  is  the  only  symptom  of  disorder,  and  is  present  for  many 
years,  the  patient  enjoying  otherwise  excellent  health.  I  have  known 
a  number  of  instances  of  this  essential  vertigo  in  which  the  tendency 
appeared  to  have  been  inherited.  If  it  do  not  break  out  until  late 
in  life,  it  is  a  matter  of  more  serious  concern. 

In  laryngeal  vertigo  ^  there  is  a  close  connection  with  epileptic  seiz- 
ures. The  chief  symptoms  are  tickling  or  burning  in  the  larynx,  fol- 
lowed by  vertigo,  loss  of  consciousness,  and  spasmodic  movements  in 
the  face  and  limbs.  The  larynx  is  healthy ;  but  in  a  case  observed 
by  Sommerbrodt  a  polypus  existed,  removal  of  which  cured  the 
affection. 

Allied  to  vertigo  is  the  condition  known  as  astasia-abasia,  the  most 
marked  characteristic  of  which  is  difficulty  in  standing  and  walking. 
Consciousness  is  not  lost,  but  sometimes  there  is  a  sense  of  giddiness. 
The  affection  is  a  manifestation  of  hysteria,  of  which  other  symptoms 
are  likely  to  be  present. 

Besides  headache  and  vertigo,  there  are  various  unnatural  sensa- 
tions, such  as  a  feeling  of  momentary  unconsciousness  without  giddi- 
ness ;  a  feeling  within  the  cranium  of  weight,  of  constriction ;  the 
feeling  described  as  a  rush  of  blood  to  the  head ;  ocular  spectra,  and 
other  false  perceptions  of  many  kinds  and  of  every  gradation.  But  I 
shall  do  no  more  than  advert  to  this  subject,  and  shall  now  consider 
some  of  the  morbid  phenomena  of  the  special  senses,  particularly  of 
the  senses  of  sight  and  hearing. 

DERANGEMENT   OF   SPECIAL   SENSES. 

Vision. — The  sense  of  vision  may  be  exalted,  impaired,  or  per- 
verted in  chsorders  of  the  brain,  whether  organic  or  functional.  It  is 
exalted  in  inflammation ;  impaired,  even  totally  lost,  in  softening,  in 
tumors,  in  apoplexy,  and  during  Adolent  hysterical  attacks  simulating 
apoplexy.  Perversions  of  the  sense  of  vision  are  more  frequent  than  its 
abolition,  and  probably  more  peculiar  to  cerebral  affections.  They  are 
of  all  kinds, — some  of  great  consequence,  others  of  but  little.  Muscm 
volitantes,  or  the  appearance_of  spots  and  various  small  objects  floating 
before  the  eye,  have  the  latter  significance ;  for  they  may  happen  in 
almost  any  form  of  cerebral  disturbance,  also  in  antemia,  in  cardiac  mal- 

1  Gasquet,  Practitioner  for  August,  1878  ;  Charcot,  Progres  Medical,  No.  17,  1879. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  77 

adies,  in  the  neuroses,  and  in  states  of  nervous  exhaustion.  They  are 
simply  the  shadows  of  vitreous  opacities  or  retinal  vessels  upon  the 
retina,  and  have  nothing  to  do  with  anything  but  the  local  condition, 
which  is  without  significance.  Of  other  manifestations  of  deranged 
sight,  such  as  illusions,  ocular  spectra,  and  phantasms,  I  shall  only 
state  that  they  are  more  common  in  sick  headache,  and  in  derangement 
of  the  mind,  temporary  or  permanent,  than  in  recognizable  organic  dis- 
ease of  the  brain.  Yet  they  are  found  in  affections  of  certain  parts  of 
the  brain  ;  for  in  disease  of  the  posterior  lobes,  as  Hughlings  Jackson 
has  observed,  colored  vision  and  optical  illusions  are  frequent. 

The  appearance  of  the  eye  is  often  of  as  much  significance  as 
the  derangement  of  sight.  In  some  cerebral  maladies  the  eye  has 
a  fixed  stare ;  in  others  the  eyelids  are  constantly  moving :  but  the 
latter  is  a  sign  more  frequent  in  chorea,  local  spasm,  and  hysteria. 
Great  brilliancy  of  the  eye  is  often  noticed  in  meningitis  and  in 
insanity. 

Derangements  of  the  ocular  mechanism  may  be  the  result  of  remote 
causes,  or,  themselves  primary,  may  become  the  starting-point  of  dis- 
order elsewhere.  In  the  first  case  their  study  is  valuable  to  the  gen- 
eral diagnostician  as  indicative  of  the  seat,  nature,  or  stage  of  many 
diseases  in  other  parts  of  the  system ;  in  the  second  case  the  diagnosis 
as  well  as  the  therapeutics  of  the  distant  and  related  disease  is  depend- 
ent upon  the  appreciation  of  the  ocular  derangement.  It  thus  becomes 
evident  that  the  abnormalities  of  the  visual  mechanism  are  of  the 
highest  importance  in  many  systemic  affections,  particularly  in  disease 
of  the  cerebro-spinal  system. 

Let  us  first  briefly  consider  the  idiopathic  derangements  of  the  eye 
that  induce  derangements  elsewhere.  Both  in  origin  and  in  result  these 
are  essentially  functional.  So  far  as  relates  to  the  eye  they  consist 
chiefly  either  in  abnormalities  of  refraction,  classed  under  the  general 
head  of  ametropia,  and  comprising  hyperopia,  astigmatism,  myopia, 
and  presbyopia,  singly  or  combined ;  or  in  incoordination  of  the  ex- 
ternal ocular  muscles,  commonly  called  insufficiency.  The  results  of 
ametropia  and  muscular  insufficiency  are  conveniently  called  eye- 
strain; and  this  condition  generally  evinces  itself  not  so  much  in 
ocular  or  visual  symptoms  as  in  functional  nervous  derangements,, 
often  far  removed  and  apparentl-y  disconnected.  For  example,  it  is 
a  well-established  fact  that  eye-strain  is  prone  to  produce  headache, 
especially  in  young  women  after  the  age  of  puberty.  These  head- 
aches are  usually  frontal,  but  may  also  be  occipital,  less  frequently 
of  the  vertex  or  diffused.  Eye-strain  is  at  times  the  starting-point 
of  choreic   symptoms,    and   even,    though   this   is    rare,    of    genuine 


78  MEDICAL  DIAGNOSIS. 

chorea.  Cases  have  been  reported^  showing  that  the  same  cause 
may  produce  functional  gastric  derangements,  hysteria,  melancholia, 
and  even  epilepsy.  The  lesson  is  obvious  that  when  the  origin  of 
these  or  other  functional  affections  is  not  otherwise  explainable,  we 
should  at  once  proceed  to  exhaust  the  possibilities  of  a  reflex  neurosis 
due  to  ocular  abnormality  or  to  some  other  peripheral  irritation. 

Hyperopia  and  hyperopic  astigmatism  are  much  the  most  frequent 
sources  of  eye-strain,  and  by  the  aid  of  a  mydriatic,  followed  by 
tests  with  the  trial-lenses,  the  diagnosis  of  the  existence  and  amount 
of  the  defect  may  be  made.  In  the  neurotic,  or  in  those  with  inter- 
current affections  and  weaknesses,  the  smallest  degree  may  become 
the  source  of  irritative  strain.  Muscular  insufficiency  is  the  next  most 
frequent  cause  of  ocular  irritation.  Simple  myopia  produces  no  strain, 
but  myopic  astigmatism,  and  presbyopia  may  sometimes  cause  it. 

Turning  now;  to  the  consideration  of  those  changes  in  the  ocular 
mechanism  which  indicate  effects  and  symptoms  of  disease  ekeiohere,  we 
find  that  disease  in  almost  any  part  of  the  organism  may  give  indi- 
cations of  its  nature  and  location  in  the  eyes.  These  symptoms, 
either  singly  or  combined,  are  of  a  threefold  nature  : 

Changes  m  the  external  appearances,  and  visible  to  the  naked  eye. 

Changes  in  the  fundus  oculi,  or  eye-ground,  as  revealed  by  the 
ophthalmoscope. 

Defects  of  vision  as  shown  by  the  subjective  report  of  the  patient. 

The  first  and  last  set  of  symptoms  require  no  very  considerable 
special  training  to  study,  but  the  use  of  the  opthalmoscope  does 
demand  it,  and  often  to  such  a  degree  that  many  are  compelled  to 
forego  invaluable  knowledge,  unless  they  can  avail  themselves  of  the 
services  of  an  expert. 

I.  Among  the  external  abnormalities  of  the  eyes  exception  must,  of 
course,  first  be  made  of  such  local  diseases  as  have  no  systemic  rela- 
tions, such  as  ecchymoses,  congestions  or  inflammations  of  the  lids 
and  conjunctiva,  trachoma,  glaucoma,  cataract,  congenital  anomalies, 
etc.  Herpes  zoster  ophthalmicus,  a  peripheral  neuritis  of  the  oph- 
thalmic branch  of  the  fifth  nerve,  is  a  dangerous  and  painful  malady, 
often,  if  not  always,  owing  to  local  causes.  Exophthalmos  is  either 
due  to  local  disease  or  is  present  as  one  of  the  main  symptoms  of 
the  affection  called  exophthalmic  goitre.  Diseases  of  the  nucleus  or 
of  the  ganglion  of  the  fifth  nerve  or  of  its  ophthalmic  division  may 
result  in  inflammation  and  destruction  of  the  eyeball. 

^  For  example,  Clinical  Illustrations  of  Reflex  Ocular  Neuroses,  by  Gould, 
Amer.  Journ.  Med.  Sci.,  Jan.  1890. 


DISEASES  OF  THE  BRAIN  AND   SPINAL   CORD.  79 

Next  in  importance  is  a  class  of  diseases  due  to  external  infection 
that  generally  points  to  a  source  of  contagion  elsewhere  in  the  or- 
ganism. Cases  of  localized  tuberculosis  of  the  conjunctiva  have  been 
reported  wherein  the  handkerchief  has  perhaps  carried  the  bacillus 
to  the  eye,  Gonorrhoeal  ophthalmia  is  a  constantly  recurring  disease 
in  ophthalmic  practice ;  but  the  most  frequent  and  frightful  is  the 
ophthalmia  of  the  new-born, — ophthalmia  neonatorum, — due  to  in- 
fection during  labor  with  the  vaginal  discharges  of  the  mother.  It  is 
said  that  the  greater  part  of  the  blindness  of  the  world  is  due  to  this 
wholly  preventable  disease. 

Affections  of  the  conjunctiva  or  lids  may  have  their  origin  in  dis- 
eases of  the  adjacent  skin  or  mucous  membrane,  and  extend  to  the 
eyes  by  simple  contiguity  of  structure.  A  close  connection  frequently 
exists  between  hay-fever,  catarrhal  and  other  diseases  of  the  nasal 
mucous  membrane,  and  similar  conditions  of  the  conjunctiva. 

Arcus  senilis,  a  ring  of  grayish  tissue-change  about  the  corneal 
limbus,  betokens  generalized  atheromatous  or  fatty  degeneration, 
chiefly  arterial  or  cardiac.  Interstitial  or  diffused  keratitis  is  nearly 
always  the  result  of  inherited  syphilis. 

Of  the  remaining  affections  of  the  external  parts  of  the  eye  in- 
dicative of  general  or  internal  disease,  the  most  important  are  those 
pertaining  to  the  muscles  of  the  eye  or  movements  of  the  globe. 
They  easily  fall  into  two  groups, — those  of  the  external  and  those  of 
the  internal  muscles. 

Strabismus,  or  squint,  may  be  due  to  local  causes,  such  as  injuries, 
or  cold,  etc.,  but  it  usually  arises  from  a  lack  of  equal  or  balanced 
power  among  the  twelve  external  muscles,  and  to  ametropia  and 
anisometropia.  The  distinctive  subjective  characteristic  of  squint  is 
double  vision.  In  examining  for  strabismus  we  observe  whether  the 
eyeball  is  turned  inward  or  outward.  In  paralysis  of  the  external 
rectus  we  have  ordinarily  an  internal  or  convergent  squint,  in  paraly- 
sis of  the  internal  rectus  an  external  or  divergent  strabismus.  In 
palsy  of  the  superior  rectus  there  is  inability  to  raise  the  eyeball  in  a 
proper  manner  above  the  horizontal  level ;  inability  to  lower  it  below 
indicates  palsy  of  the  inferior  rectus.  Strabismus  due  to  local  causes 
must  be  distinguished  from  true  paralytic  squint  due  to  more  cen- 
trally located  lesions.  It  musi  also  be  distinguished  from  spastic 
action  of  the  muscles  caused  by  irritative  intracranial  injuries.  In 
both  the  latter  cases  there  is  a  conjugate  or  common  movement  of 
both  eyes  to  one  side  or  to  the  other,  called  conjugate  lateral  deviation  ; 
the  head  often  shares  in  the  lateral  movement.  In  spastic  irritative 
lesions  of  the  cortex  the  eyes  are  turned  from  the  side  of  the  injury ; 


80  MEDICAL  DIAGNOSIS. 

in  paralytic  or  destructive  lesions  they  are  turned  towards  it.  The 
eyes,  as  has  been  said,  look  at  the  lesion  in  paralysis,  away  from  it 
in  spasm.  The  symptom,  however,  owing  to  its  frequently  tempo- 
rary existence,  and  also  to  the  fact  that  it  may  arise  as  an  indirect 
symptom,  must  not  be  relied  upon  except  in  conjunction  with  others 
and  when  continuing  for  several  weeks.-^  The  seat  of  the  lesion  may 
be  in  the  cortex,  the  internal  capsule,  or  the  pons  ;  in  the  latter  case 
the  symptoms  are  direct  and  the  deviation  of  the  eyes  is  the  reverse 
of  that  given  above  :  the  eyes  in  paralysis  look  away  from  the  lesion  ; 
in  spasm,  towards  it.  If  in  lesions  of  the  pons  the  sixth  nerve  nucleus 
be  included,  there  is,  of  course,  paralysis  of  the  external  rectus,  so 
that  the  corresponding  eye  cannot  be  rotated  outward  past  the  middle 
line,  whilst  the  other  eye  cannot  be  rotated  inward  past  the  middle 
line.  This  associated  movement  of  the  other  eye  will  not  be  impaired 
if  the  injury  to  the  sixth  nerve  be  between  the  nucleus  and  the  globe. 

Owing  to  the  peculiar  position  of  its  nucleus  and  the  long  course 
of  exit  of  the  sixth  nerve^  its  exclusive  paralysis  is  the  most  frequent 
of  single  nerve  palsies.  It  is  peculiarly  liable  to  paralysis  from  indi- 
rect or  pressure  causes,  but  if  connected  with  paralysis  of  the  oppo- 
site side  of  the  body  and  with  other  symptoms  of  brain  disease,  it 
clearly  points  to  a  lesion  of  the  pons.  In  consequence  of  the  close 
anatomical  relations  of  their  nuclei,  palsies  of  the  sixth  and  facial 
nerves  are  frequently  associated.  Other  nerves  originating  in  the 
pons  are  liable  to  implication.  Next  to  the  sixth  the  third  nerve  is  the 
one  most  often  paralyzed,  and  in  proportion  to  the  number  of  twigs 
involved  and  the  completeness  of  their  palsy  is  there  a  probability 
of  a  lesion  at  the  base  of  the  brain.  The  various  paralyses  of  the 
external  ocular  muscles  are  usually  attended  with  double  vision, 
diplopia. 

Ptosis  may  exist  either  with  or  without  involvement  of  other 
third-nerve  branches,  but  in  any  case  the  value  of  the  droop  of  the 
upper  eyelid  as  a  localizing  symptom  is  somewhat  indeterminate.  If 
of  one  eye  alone,  ptosis  usually  indicates  a  cortical  lesion,  unless  due 
to  evidently  local  causes.  In  paralysis  of  the  third  nerve  we  have, 
besides  the  ptosis,  dilatation  of  the  pupil  of  moderate  extent.  Inability 
to  close  the  eyehds  is  associated  with  paralysis  of  the  facial  nerve. 

As  regards  the  nature  of  the  lesion,  the  ocular  symptoms  gen- 
erally give  little  definite  indication. 

^  The  direct  symptoms  are  those  intimately  dependent  upon  the  lesion  of  a 
pari ;  the  indirect  or  distant  symptoms  are  those  due  to  disturbances  of  circula- 
tion, to  pressure,  to  the  reflex  or  inhibitory  effects  at  other  points  than  the  seat 
of  injury. 


DISEASES  OF  THE   BRAIN  AND   SPINAL   CORD.  81 

Abnormalities  of  the  pupils  are  understood  by  remembering  that 
the  third  nerve  controls  the  contractile  mechanism  and  the  cervical 
sympathetic  the  dilating  mechanism.  Hence  an  unusual  diminution 
or  increase  of  either  innervation,  especially  of  the  first,  causes  alter- 
ations of  the  pupils  at  once.  Irritative  cerebral  lesions  thus  produce 
contraction,  whilst  lesions  which  destroy  cerebral  function  produce 
morbid  dilatation.  The  state  of  the  pupil  in  tumors,  hemorrhage,  and 
inflammatory  conditions  of  the  brain  may  thus  furnish  us  with  most 
serviceable  indications  of  the  extent  and  destructiveness  of  the 
injury.  When  but  one  pupil  is  abnormal,  the  rule  above  given 
serves  to  indicate  lesion  of  the  corresponding  half  of  the  cerebrum, 
irritative  or  paralytic  according  to  the  degree  of  the  injury.  Yet  one- 
sided contraction,  like  one-sided  dilatation,  may  also  be  owing  to 
tumors  at  the  root  of  the  neck.  Hemorrhage  or  effusion  into  the 
pons  or  lateral  ventricles,  when  small  or  irritative,  produces  con- 
traction ;  but  if  large,  permanent  dilatation.  Certain  drugs,  such  as 
opium,  contract  the  pupil ;  belladonna,  chloral,  and  cocaine  dilate  it. 
We  also  find  dilatation  of  both  pupils  in  chlorosis.  If  the  foot  be 
pricked,  the  pupils  dilate,  provided  the  iris  be  uninjured  and  the 
sensory  columns  be  intact.  In  epileptics  this  reflex  excitability  is 
greatly  diminished.^ 

The  pupillary  reaction  to  light  may  be  useful  in  diagnosticating 
the  location  of  a  lesion,  whether  beyond  the  corpora  cjuadrigemina  or 
not.  If  beyond,  the  pupillary  reflex  will  be  retained,  despite  the  loss 
of  sight.  Lesions  of  the  spinal  cord  and  of  the  sympathetic  nerve 
produce  results  the  reverse  of  cerebral  disease :  irritative  lesions 
dilate,  paralytic  lesions  contract.  In  this  connection  the  Argyll- 
Robertson  pupil — the  light-reflex  lost,  the  accommodative  reflex  re- 
tained, of  a  myopic  pupil — is  of  value  as  indicating,  often  early,  scle- 
rosis of  the  posterior  columns  of  the  cord.  When  hemianopsia  is 
due  to  disease  of  the  optic  tract,  the  pupil  fails  to  react  to  the  stimu- 
lation of  light  reflected  upon  the  blind  half  of  the  retina  ;  contracting, 
however,  if  the  lesion  be  situated  in  the  cerebral  hemisphere.  Paral- 
ysis of  the  accommodation  may  exist  independently  of  pupillary  in- 
volvement, and  its  significance  is  that  of  paralysis  of  other  branches 
of  the  third  nerve.  Paralysis  of  many  or  of  all  the  muscles  of  both, 
eyes,  ophthalmoplegia ^  is  usually  due  to  a  lesion  of  the  nuclei  of  the 
supplying  nerves.  It  is  especially  due  to  lesions  of  the  nuclei  in  the 
gray  matter  of  the  Sylvian  aqueduct. 

II.  Abnormal  changes  in  the  fundus  of  the  eye  may  be   of   great 

^  Lawson,  West  Piiding  Reports,  vol.  iv. 


82  MEDICAL  DIAGNOSIS. 

diagnostic  value,  and  in  almost  every  case  of  circulatory  or  nervous 
disease  the  ophthalmoscope  gives  valuable  hints  concerning  the  gen- 
eral disorder.  With  few  exceptions  these  changes  are  symptomatic, 
and  do  not  arise  from  local  disease. 

We  should  invariably  examine  with  the  ophthalmoscope  the  eyes 
of  patients  suspected  of  having  disease  of  any  part  of  the  cerebro- 
spinal nervous  system.  Changes  in  the  eye,  indeed,  often  occur  early 
enough  to  be  the  first  certain  sign  of  disease,  and  this,  too,  with- 
out any  impairment  of  sight ;  on  the  other  hand,  lesions  indicating 
cerebral  or  other  organic  affection  have  been  found  in  cases  in  which 
failure  of  sight  was  alone  complained  of.  But  particularly  is  the 
ophthalmoscope  valuable  in  enabling  us  to  differentiate  organic  from 
functional  affections.  It  tells  us  of  extension  of  congestion  or  of  in- 
flammation of  the  brain  to  the  internal  structures  of  the  eye,  or  of 
the  amount  of  resistance  offered  to  the  circulation  within  the  cranium. 
This  resistance  may  either  arise  from  a  marked  "  coarse"  lesion,  or 
may  make  itself  felt  through  the  sympathetic  nervous  system. 

The  changes  in  connection  with  organic  disease  have  been  ob- 
served chiefly  in  the  retina,  the  optic  disk,  and  the  choroid.  In  using 
the  ophthalmoscope  for  medical  diagnosis  we  pay  particular  attention,  to 
these  structures ;  especially  do  we  note  the  disk,  its  color  and  size, 
and  the  pigment  around  its  edges,  the  region  of  the  macula,  the  size 
and  appearance  of  the  arteries  and  veins,  whether  diminished,  en- 
larged, or  tortuous,  whether  there  are  exudations  or  hemorrhages  in 
the  course  of  the  vessels,  and  in  what  part  of  the  eye-ground  the 
patches  are  most  marked, 

Hyperoemia,  or  increased  redness,  is  due  to  local  causes  ;  and  the 
fundus  changes  in  myopia,  astigmatism,  retinitis  pigmentosa,  and 
some  forms  of  choroiditis  are  also  to  be  excepted.  In  diseases  of  the 
blood  and  the  blood-making  organs,  the  indications  are  remarkably 
clear.  Retinal  hemorrhages  are  a  common  concomitant  of  such  gen- 
eral diseases  as  albuminuria,  diabetes,  anaemias,  cardiac  valvular  dis- 
ease, arterial,  atheromatous,  and  fatty  degenerations,  chronic  malaria, 
and  other  febrile  conditions.  Embolism  of  the  central  artery  of  the 
retina,  causing  unilateral  blindness,  points  to  cardiac  valvular  disease. 
There  is  a  grayish  discoloration  about  the  macula,  with  a  central 
cherry-red  spot.  Tortuosity,  beading,  bulging,  and  irregularities  in 
the  size  of  the  arteries, .  with  pressure  on  the  veins,  oedema,  and 
hemorrhage,  are  indicative  of  arteriosclerosis.  Simple  anaemia  is 
at  once  recognized  by  the  transparency  of  the  blood-columns,  and 
lukcemia  and  pernicious  anoimia  produce  characteristic  changes  in  the 
eye-ground,  especially  the  last,  with  retinal  oedema  and  hemorrhages, 


DISEASES   OF  THE   BRAIN   AND   SPINAL   CORD.  83 

disk-discoloration,  arterial  pallor,  and  venous  distention.  Albuminuric 
retinitis  is  common,  but  not  invariable  in  albuminuria.  The  typical 
fundus  changes  consist  in  an  early  stage  of  haziness  of  the  papilla 
and  central  part  of  the  fundus,  slight  hemorrhages,  and  faint  grayish 
discolorations.  Later,  v^^hite  dots  or  splotches  are  grouped  about  the 
macula,  or,  flame-like,  radiate  from  it.  Striate  hemorrhages  are  scat- 
tered over  the  fundus,  the  papilla  is  oedematous,  and  its  limits  are 
obscured.  The  ophthalmoscopic  signs  of  diabetic  retinitis  are  very 
similar.  Visual  disturbances,  hov^ever,  do  not,  in  either  case,  stand 
in  any  exact  ratio  to  the  defects  of  the  eye-ground. 

Atrophy  of  the  optic  nerve,  recognizable  by  the  whiteness  or  discol- 
oration of  the  disk,  failure  of  vision,  even  to  blindness,  may  some- 
times seem  to  have  no  remote  causes,  but  is  commonly  associated 
with,  or  is  a  result  of,  diseases  or  lesions  of  the  spinal  cord  or  the 
brain,  toxic  substances  in  the  blood,  papillitis,  etc. 

Papillitis,  optic  neuritis,  "  choked  disk,"  is  a  symptom  of  most 
decided  diagnostic  value.  The  picture  is  easily  recognized,  consisting 
in  a  swollen  red  disk,  the  edges  and  vessels  of  which  are  obscured  by 
a  "  woolly,"  striate  blurring  extending  to  the  adjacent  retina.  This 
condition  is  always  symptomatic,  and  in  the  large  majority  of  cases 
points  to  tumor  of  the  brain,  though  other  intracranial  diseases  may 
produce  it.  From  papillitis,  however,  nothing  can  be  argued  as  to  the 
nature  or  location  of  the  tumor  or  other  affection.  It  is  often  not  a 
late  symptom,  and  unimpaired  vision  may  coexist.  Optic  neuritis 
has  been  observed  after  measles  and  scarlet  fever,  also  after  malaria 
and  typhoid  fever.^ 

Choroidal  inflammations  are  chiefly  distinguishable  by  the  striking 
color  and  pigment  changes  of  the  fundus.  Plastic  choroiditis  is  com- 
monly secondary  to  meningeal  affections  and  prostrating  fevers  ;  puru- 
lent choroiditis,  to  local  or  general  infection  or  septicsemia.  Dissemi- 
nated and  central  choroiditis,  or  choroido-retinitis,  is  frec|uently  the 
result  of  syphilis.  The  choroid  is  pecuharly  liable  to  become  the  seat 
of  tuberculous  growths. 

III.  Passing  now  to  the  consideration  of  purely  subjective  visual 
derangements,  it  becomes  highly  necessary  to  determine  first  whether 
such  defects  are  due  to  refraction-errors,  insufficiencies,  and  other 
local  causes,  or  if  they  are  secondary  and  symptomatic.  Unless  other 
indications  are  present,  the  complaint  of  headache,  especially  if 
frontal,  weariness  or  pain  of  the  eyes  after  near  work,  affections  of 
the  lids  and  conjunctiva,  conjoined  with  general  irritability  and  func- 


^  White,  Journal  of  the  Amer.  Med.  Assoc,  Oct.  1893. 


84  MEDICAL  DIAGNOSIS. 

tional  gastric  derangements,  almost  invariably  indicate  eye-strain  as 
primary.  Simple  inability  to  see  distant  objects  clearly,  without  other 
symptoms,  local  or  general,  indicates  myopia. 

Amblyopia^  due  to  the  excessive  indulgence  in  tobacco  or  alcohol, 
has  but  a  single  objective  sign  :  an  unusual  pallor  of  the  temporal 
portion  of  the  papilla.  There  is  deterioration  of  visual  acuity,  to 
which  subnormal  color-perception  may  be  added.  Amblyopia  some- 
times occurs  also  as  a  manifestation  of  hysteria  and  in  association 
with  migraine.  It  has  further  been  observ^ed  as  a  symptom  of  intoxi- 
cation with  quinine,  iodoform,  lead,^  or  after  sexual  excesses ;  or  the 
defective  acuteness  of  vision  shows  itself  as  a  day-blindness  or  as  a 
night-blindness  ;  or  takes  the  form  of  contracted  fields  of  vision,  or 
of  color-blindness.  Marked  visual  deterioration  of  a  single  eye  should 
lead  to  inquiry  for  extra-local  causes.  It  may  be  due  to  disease  of 
the  corresponding  optic  nerve.  When  ametropia  has  been  excluded 
and  the  above-described  ophthalmoscopic  signs  are  wanting,  the  cause 
must  be  sought  in  disease  of  other  organs.  Paresis,  and  even  paral- 
ysis of  the  accommodation,  and  visual  failure,  are  not  infrequent  as 
reflex  neuroses  from  peripheral  irritation  of  other  parts.  Cases  of 
abnormalities  of  dentition  and  other  dental  troubles  producing  such 
visual  defects  have  been  frequently  reported.  Menstrual  difficulties, 
masturbation,  the  influence  of  pregnancy  and  lactation,  may  some- 
times account  for  obscure  ocular  troubles.  Hemeralopia,  night-blind- 
ness, due  to  deficient  nutrition  of  the  general  system,  has  been  traced 
to  insufficient  food.^ 

Modifications  of  the  color-fields  have  been  found  chiefly  in  hys- 
terical patients.  The  field  for  red  and  green,  always  the  narrower, 
shows  the  restriction  most  markedly. 

The  most  important  ocular  sign  of  cerebral  disease,  and  one  in- 
variably pointing  to  intracranial  affection  is  hemianopsia,  or  loss  of 
vision  of  the  halves  of  the  fields.  The  most  common  variety  is  that 
called  homonymous  lateral  hemianopsia,  in  which  the  loss  is  either 
of  the  temporal  half  -of  one  eye  and  of  the  nasal  half  of  the  other, 
or  vice  versa,  a  vertical  line  nearly  through  the  centre  being  the 
dividing  line.  There  are  three  other  forms  of  hemianopsia,  called 
temporal,  nasal,  and  altitudinal,  in  which  the  half-fields  are  respec- 
tively the  two  temporal,  the  two  nasal,  with  the  dividing  line,  as 
previously,  perpendicular,,  or  the  two  dark  half-fields  are  the  upper 


1  De  Schweinitz,  The  Toxic  Amblyopias,  1896. 

"2  Kubli,  Archiv  fur  Augenheilkunde,  June,  1887,  who  describes  three  hundred 
and  twenty  cases  occurring  during  the  Russian  church-fasts. 


DISEASES  OF  THE   BRAIN  AND   SPINAL   CORD.  85 

or  the  lower  halves,  with  the  dividmg  line  horizontal.  These  three 
varieties  are  seldom  met  with,  and,  from  the  peculiar  anatomical  re- 
lations of  the  optic  chiasm  or  commissure,  are  readily  recognized  as 
the  results  of  lesions  of  this  part,  either  at  one  side  or  the  other, 
above  or  below.  Homonymous  lateral  hemianopsia  always  indicates 
lesion  beyond  the  chiasm.  If  the  hemianopsia  be  "  relative," — in- 
volving only  a  part  of  the  perceptions  of  light,  form,  and  color, — it 
must  necessarily  proceed  from  a  partial  lesion  of  the  common  visual 
centre  situated  in  the  cuneus  of  the  occipital  lobe.^  But  if  the 
hemianopsia  be  absolute, — with  complete  loss  of  light,  form,  and 
color  sense, — the  lesion  may  be  either  one  affecting  the  entire  visual 
centre  of  one  side,  or  one  rendering  wholly  functionless  the  fibres  of 
one  radiation,  internal  capsule,  or  optic  tract.  If  the  latter  were  the 
case  there  would  almost  certainly  be  other  intercurrent  or  general 
symptoms,  such  as  paralysis  of  other  cranial  nerves,  hemianaesthesia, 
some  form  of  aphasia,  or  hemiplegic  symptoms.  A  symptom  of 
great  value  in  locating  the  lesion  of  hemianopsia  is  the  hemiopic 
pupil.  Convergence  of  a  narrow  cone  of  light  upon  the  insensitive 
half  of  the  retina  yields  no  pupillary  reflex  if  the  lesion  be  in  the 
optic  tract ;  if  the  pupil,  under  such  stimulus,  contract,  the  lesion 
must  be  beyond  the  tract.  The  intracranial  affection  giving  rise  to 
the  hemianopsia  may  be  of  malarial  origin,  and  it  and  the  associate 
cerebral  symptoms  will  disappear  under  active  antimalarial  treatment.^ 

Mind-blindness,  physical  vision,  but  failure  to  realize  the  psychical 
import  of  the  things  seen,  sometimes  a  symptom  of  general  paralysis 
and  obscure  cerebral  disease,  indicates  a  cortical  lesion  in  the  occipi- 
tal or  occipito-temporal  lobe,  near  by  if  not  conterminous  with  the 
visual  centre. 

Hearing. — As  regards  the  sense  of  hearing,  the  same  may  be  said 
as  of  vision.  It,  too,  is  perverted  and  impaired  in  various  cerebral 
affections.  Yet,  to  be  certain  that  the  cause  of  the  difficulty  is  cere- 
bral, the  ear  must  first  be  examined  with  reference  to  any  physical 
imperfection  ;  and  in  doing  so  we  may  by  means-  of  the  otoscope  get 
an  idea  of  the  vascularity  of  the  drum,  and  be  led  from  this  to  infer 
the  condition  of  the  vessels  of  the  brain.  We  must  also  examine  the 
throat  and  the  condition  of  the  Eustachian  tube,  for  catarrhal  inflam- 
mation extending  to  the  middle  e^r  may  give  rise  to  a  form  of  aural 
vertigo. 

^  Seguin  limits  the  centre  to  the  cuneus  ;  Nothnagel  makes  it  include  also  the 
posterior  portion  of  the  superior  occipital  convolution. 

^  See  my  paper  on  Malarial  Paralysis,  with  eye  examinations  by  Harlan,  in 
International  Clinics,  vol.  iii.,  Ser.  I.,  Oct.  1891. 

6 


86  MEDICAL  DIAGNOSIS. 

Great  acuteness  of  hearing  and  intolerance  of  sound  are  gener- 
ally symptoms  of  extreme  nervous  irritability,  or  of  beginning  cere- 
bral inflammation.  Deafness  may  be  owing  to  softening  of  portions 
of  the  brain ;  but  Ferrier  tells  us  that  it  is  not  met  with  in  destructive 
lesions  of  the  cortex.  Deafness  is  also  found  as  a  temporary  and  by 
no  means  unfavorable  symptom  in  the  continued  fevers.  Imaginary 
sounds  and  ringing  noises  in  the  ear,  or  tinnitus  auriuni,  are  frequent 
accompaniments  of  cerebral  disorders.  But  the  latter  is  encountered 
in  so  many  different  conditions — in  diseases  of  the  cerebral  vessels, 
in  congestion  of  the  brain,  in  Meniere's  disease,  in  affections  of  the 
heart,  in  ansemia — that  it  is  a  sign  of  little  moment ;  and,  in  truth, 
its  most  usual  cause  is  local, — namely,  an  accumulation  of  wax  in  the 
meatus. 

There  is  a  form  of  reflex,  the  so-called  binaural  reflex  described 
by  Gelle,  the  disappearance  of  which  is  of  value,  provided  we  have 
been  able  to  exclude  disease  of  the  ear.  In  health,  when  a  vibrating 
tuning-fork  is  placed  before  one  ear,  while  pressure  is  made  by  means 
of  a  Politzer  bag  on  the  canal  of  the  other,  a  diminution  of  the  sound 
of  the  fork  is  noticed.  In  disease  of  the  cervical  cord  this  reflex  dis- 
appears. 

DERANGED    REFLEXES. 

Derangement  of  the  reflex  action  plays  a  most  important  part  in 
the  study  of  diseases  of  the  nervous  system.  Each  action  is  brought 
about  by  a  sensory  nerve  that  conveys  the  impression  to  the  centre, 
by  a  motor  nerve  that  transmits  the  impulse  from  the  centre  to  the 
periphery,  and  by  a  reflex  centre  between  the  two  in  the  spinal  cord 
connecting  the  roots  of  the  sensory  and  motor  nerves,  which  with 
them  forms  the  "  reflex  arc."  The  reflex  centre  is  to  some  extent 
under  brain  control. 

There  are  two  forms  of  reflexes  to  be  especially  studied, — the 
cutaneous  or  superficial,  produced  by  stimulating  the  skin,  and  the 
deep  reflexes,  the  muscle  or  tendon  reflexes,  evoked  by  tapping 
muscles  or  tendons. 

The  superficial  may  be  almost  everywhere  excited  by  tickling  or 
gently  stimulating  the  skin.  The  most  usual  ones  to  be  noted  are  the 
reflex  of  the  sole  of  the  foot,  the  jjlantar  reflex;  and  that  of  the  palm 
of  the  hand,  the  palmar  reflex.  The  former,  when  normal,  attests  the 
integrity  of  the  reflex  arc  at  the  lower  end  of  the  cord ;  the  palmar 
reflex,  contraction  of  the  digital  flexors  by  tickling  the  palm,  indicates 
a  normal  state  of  the  reflex  arc  through  a  greater  part  of  the  cervical 
enlargement.  Other  superficial  reflexes  which  may  be  mentioned  are 
the  cremaster  reflex,  the  drawing  up  of  the  testicle  excited  by  stimu- 


DISEASES   OF  THE  BRAIN  AND   SPINAL   CORD.  87 

lating  the  front  and  inner  side  of  the  thigh,  and  originating  in  the 
cord  at  a  point  between  the  first  and  second  lumbar  pairs  ;  the  gluteal 
reflex^  the  contraction  caused  by  irritating  the  skin  over  the  buttock, 
and  showing  the  integrity  of  the  cord  at  the  fourth  and  fifth  lumbar 
nerves  ;  the  abdominal  reflex,  a  contraction  in  the  abdominal  walls 
caused  by  scratching  the  skin  on  the  side  of  the  abdomen,  and  de- 
pending on  the  action  of  the  cord  from  the  eighth  to  the  twelfth 
dorsal  nerve ;  the  epigastric  reflex,  an  epigastric  dimpling  produced  by 
stimulating  the  side  of  the  chest  in  the  fifth  or  sixth  intercostal  space, 
and  indicating  integrity  of  the  cord  from  the  fourth  to  the  seventh 
pair  of  dorsal  nerves  ;  the  scapular  reflex,  a  contraction  by  stimulation 
of  the  scapular  muscles,  and  bespeaking  the  integrity  of  the  reflex  arc 
at  the  level  of  the  upper  two  or  three  dorsal  and  lower  two  or  three 
cervical  nerves  ;  the  erector  sjnncB,  showing  itself  by  stimulating  the 
skin  along  the  border  of  the  erector  spinae  muscle,  the  contraction  of 
these  muscles  showing  the  healthy  state  of  the  cord  in  the  dorsal 
region.  Other  reflexes  of  indeterminate  utility  are  the  platysma  reflex, 
dilatation  of  the  pupil  upon  pinching  the  platysma  myoides  muscle. 
Among  cranial  reflexes,  the  more  noteworthy  are  the  iris-contraction 
upon  exposure  of  the  retina  to  light ;  the  eyelid-closure  from  irritation 
of  the  conjunctiva ;  the  pharyngeal,  laryngeal,  and  palatal  reflexes 
(cough,  swallowing,  etc.)  from  irritation  of  these  parts ;  and  nasal 
reflexes,  as  in  sneezing.  The  aural  reflexes  are  of  some  value  in  ap- 
preciating disease  of  the  cervical  part  of  the  cord.^  In  disease  these 
superficial  reflexes  are  often  absent.  Thus,  disease  of  one  cerebral 
hemisphere  diminishes  or  destroys  them  on  the  other  side,  the  para- 
lyzed side  of  the  body.  In  pregnancy  all  reflexes  are  increased. 
The  superficial  reflexes  are  much  influenced,  increased  or  diminished, 
by  psychical  causes.^ 

The  reflex  phenomena  connected  with  the  tendons  give  us  the 
best  illustration  of  the  so-called  deep  reflexes.  The  tendon  of  the 
patella  is  the  one  most  readily  studied ;  and  if,  the  body  being  bent 
forward,  we  strike  abruptly  the  tendon  of  the  patella  just  below  the 
knee-cap,  after  rendering  the  ligamentum  patellas  tense  by  flexing  the 
knee  at  a  right  angle  while  one  knee-joint  rests  upon  the  other,  or 
the  leg  hangs  loosely  over  a  supporting  arm,  a  sudden  contraction 
takes  place  in  the  quadriceps  femoris  muscle,  and  the  foot  is  jerked 
upward.  When  very  slight,  the  knee-jerk  is  most  readily  elicited  by 
a  tap  with  the  percussion  hammer.     This  reflex  is  largely  due  to  a 


1  Amer.  Journ.  Med.  Sci.,  Dec.  1888. 

^  Jendrassik,  Deutsches  Archiv  fiir  klinische  Medicin,  April,  1894. 


88  '  MEDICAL   DIAGNOSIS. 

muscle  reflex  action  dependent  upon  the  spinal  cord.  There  are 
several  instruments  for  measuring  the  knee-jerk.  A  good  one  is 
that  of  Hayne's.-^ 

The  knee-jerk  is  found  in  health,  and  is  markedly  increased  in 
disease  of  the  pyramidal  tracts,  in  heightened  irritahility  of  the  gray 
substance  of  the  spinal  cord,  in  many  tumors  of  the  brain,  in  cerebro- 
spinal sclerosis,  in  lateral  sclerosis,  after  epileptic  seizures  or  unilateral 
convulsions,  in  spinal  irritability.^  It  is  absent  in  locomotor  ataxia, 
even  at  an  extremely  early  age  of  this  affection.  It  is  also  abolished 
in  infantile  paralysis,  in  destructive  lesions  of  the  lower  part  of  the 
cord,  in  neuritis  of  the  lower  extremities,  in  advanced  stages  of 
pseudohypertrophic  paralysis,  and,  temporarily  at  least,  as  pointed 
out  by  Hughlings  Jackson,  in  meningitis  and  in  instances  of  emphysema 
and  other  maladies  in  which  the  blood  has  become  venous  to  an  ex- 
treme degree.^  Exceptionally  it  may  be  absent  in  healthy  persons  ;  I 
have  known  it  so  in  three  brothers. 

The  tendo-Achillis  jerk  is  elicited  by  tapping  the  tendon  when  the 
leg  is  extended  and  the  foot  flexed.  If  this  reflex  be  exaggerated  it 
may  appear  when  the  muscles  on  the  anterior  part  of  the  leg  or  the 
tibia  are  struck.     This  constitutes  the  front-tap  contraction. 

The  biceps  reflex  is  developed  by  tapping  the  tendon  of  the  biceps. 
This  leads  to  contraction  of  the  biceps  muscle.  Its  meaning  is  the 
same  as  that  of  the  knee-jerk.  .  Tapping  on  the  front  of  the  wrist 
gives  rise  to  contraction  in  the  flexors  of  the  fingers  ;  striking  the 
tendon  of  the  triceps  above  the  olecranon  causes  contraction  in  the 
triceps.  This  is  especially  marked  in  the  irritable  muscle  of  the 
early  and  late  rigidity  of  hemiplegia.  Another  deep  reflex  is  the 
periosteal.  It  is  produced  by  tapping  the  bones  of  the  forearm  or  leg, 
which  gives  rise  to  active  contraction  of  the  muscles,  and  indicates  a 
disease  of  the  spinal  cord,  especially  amyotrophic  lateral  sclerosis, 
A  slight  jaw-jerk.^  elicited  by  striking  the  lower  jaw  obliquely  when 
the  mouth  is  slightly  opened,  is  present  in  health,  and  exaggerated  in 
spastic  states.  Under  the  latter  conditions  active  flexion  of  the  great 
toe  gives  rise  to  clonus.  The  toe-reflex,  described  by  Sinkler,  is  met 
with  only  when  the  knee-jerk  and  ankle  clonus  are  highly  developed. 
The  great  toe  is  strongly  flexed ;  immediately  involuntary  flexion  of 
the  foot  follows,  then  of  the  leg,  and  of  the  thigh  on  the  pelvis. 

In  some  instances  of  disease  the  reflex  phenomena  are  produced 


1  Phila.  Med.  Journ.,  April  1,  1899. 

^  Hughlings  Jackson,  Medical  Times  and  Gazette,  Feb.  1881. 

3  Brit.  Med.  Journ.,  1892,  No.  1614. 


DISEASES   OF  THE   BRAIN  AND   SPINAL   CORD.  89 

on  the  side  opposite  to  the  one  acted  on.  These  crossed  reflexes  are 
not  unfrequently  met  with  in  posterior  spinal  sclerosis,  and  are  not 
merely  associated  contractions.  A  tap  on  the  tibia  near  its  middle 
generally  induces  contractions  of  the  quadriceps  femoris  ;  and  it  is 
often  followed  by  contractions  of  the  quadriceps  of  the  opposite  leg 
when  both  the  pyramidal  tracts  are  diseased.^ 

The  phenomenon  called  reinforcement  of  a  reflex  may  have  its  use 
and  significance  in  the  diagnosis  of  doubtful  or  obscure  cases.  In 
testing  the  muscular  power  of  the  hand  by  the  dynamometer,  it  is 
well  known  that  one  hand  has  greater  power  if  the  other  hand  be 
forcibly  and  synchronously  clinched.  Any  reflex  is  heightened  by 
coincident  muscular  exertion  of  other  parts  than  those  being  tested, 
and,  if  a  desired  reflex  be  difficult  to  elicit,  it  may  be  brought  out  by 
muscular  tension  of  some  other  part  of  the  body.  Strong  irritation 
of  the  skin  acts  in  the  same  way.  So  slight  an  outlay  of  force  as 
that  of  winking  will  increase  the  force  of  the  knee-jerk,  if  correctly 
timed.^  When  the  muscle  is  cut  off  from  connection  with  the  spinal 
centres,  as  in  the  late  stages  of  locomotor  ataxia,  the  reflex  and  any 
reinforcement  are  alike  impossible. 

Very  similar  to  the  knee  phenomenon  is  the  foot  phenomenon,  or 
ankle  clonus,  although  its  reflex  character  is  more  doubtful.  It  is  pro- 
duced if  the  foot  be  suddenly  brought  into  complete  flexion  by  the 
hand  pressed  against  the  sole,  the  leg  being  semiflexed,  and  still  more 
readily  if  subsequently  the  tendo  Achillis  be  quickly  tapped.  A  kind 
of  convulsive  shaking  of  the  foot  results,  dependent  on  alternate 
contraction  and  relaxation  of  the  anterior  tibial  and  calf  muscles. 
Ankle  clonus  is  at  times,  but  not  often,  observed  in  healthy  persons, 
although  it  is  susceptible  of  being  cultivated ;  in  lateral  sclerosis  it  is 
developed  to  an  extraordinary  degree.  Indeed,  it  is  marked  in  the 
class  of  affections  in  which  the  knee  reflex  is  excessive.  When  pro- 
duced solely  by  sudden  passive  tension  of  the  muscle,  it  is  indicative 
of  structural  change  in  the  spinal  cord.^ 

Wrist  clonus  may  be  induced  in  the  late  rigidity  of  hemiplegia  hy 
pressing  the  hand  backward  so  as  to  produce  extreme  extension  at 
the  wrist. 

A  muscle-jerk  is  obtained  by  directly  striking  a  muscle,  as,  for 
instance,  the  quadriceps  femoris  ;  a  contraction  ensues.  The  muscle- 
jerk  may  be  manifest  when  the  tendon-jerk  has  ceased ;  it  may  be, 

^  Ross,  op.  cit.,  vol.  i. 

^Mitchell  and  Lewis,  Tendon-  and  Muscle-Jerk,  Amer.  Journ.  Med.  Sci.,  vol. 
xcii.,  1886. 

^  Gowers,  Diseases  of  the  Nervous  System. 


90  MEDICAL  DIAGNOSIS. 

indeed,  found  to  be  exaggerated.  Unlike  the  tendon-jerk,  therefore, 
it  is  independent  of  disease  or  injury  to  the  motor  or  sensory  nerves 
of  a  muscle,  or  of  damage  to  its  related  spinal  centre. 

If  a  muscle  be  suddenly  relaxed,  a  slow  tonic  contraction  follows 
which  may  last  for  some  minutes.  The  phenomenon  is  best  witnessed 
in  the  tibialis  anticus,  but  is  rarely  seen  in  the  muscles  of  the  arm. 
This  pardoxical  muscular  contixiction  has  no  definitely  ascertained 
value.     It  is  sometimes  met  with  in  the  early  stages  of  locomotor 

DERANGED   MOTION. 

The  chief  manifestations  of  deranged  motion  resolve  themselves 
into  the  phenomena  called  paralysis,  ataxia,  tremor,  spasms,  and  con- 
vulsions. 

Paralysis. — When  we  speak  of  paralysis,  we  mean  a  loss  of  the 
power  of  motion,  although  there  is  the  impulse  of  the  will  to  move 
the  affected  part.  It  is  true,  there  is  also  a  paralysis  of  sensation,  a 
complete  anaesthesia,  which  may  be  conjoined  with  the  paralysis  of 
motion ;  but  the  latter  often  happens  alone,  and  is  the  morbid  state 
meant  when  we  use  the  word  paralysis  without  qualifying  it.  A  slight, 
incomplete  paralysis  is  called  "  paresis,"  and  this  term  is  especially 
employed  when  the  loss  of  power  exists  without  demonstrable  organic 
change. 

Paralysis  may  involve  one  member,  and  is  then  known  as  mono- 
plegia^ such  as  brachial  or  crural;  one-half  of  the  body,  hemijjlegia; 
both  sides  of  the  body,  diplegia  ;  of  the  lower  extremities,  paraplegia. 
When  power  is  lost  in  the  extremities  on  one  side  and  facial  muscles  on 
the  other  side,  the  paralysis  is  designated  "  alternate"  or  "  crossed." 

Palsy  may  come  on  rapidly  or  appear  slowly.  But  under  any  cir- 
cumstances it  is  not  a  disease,  but  a  symptom.  The  causes  which 
give  rise  to  paralysis  may  be  thus  summed  up  : 

Paralysis  due  to  a  lesion  or  any  morbid  condition  of  the  nervous  centres. 
— Hemorrhage  into  or  softening  of  the  central  nervous  textures,  or 
any  other  process  which  materially  alters  or  compresses  them,  or  in- 
terrupts the  main  conducting  paths,  occasions  loss  of  power  in  the 
part  over  which  their  influence  in  health  extends.  The  complete 
paralysis  attending  most  of  the  diseases  of  the  brain  and  of  the  spinal 
cord  belongs,  therefore,  in  this  category. 

But  besides  these  palsies  of  organic  origin  there  are  functional 
palsies.,  dependent  upon  what,  so  far  as  we  are  aware,  is  simply  a 
functional  derangement  of  the  great  centres  of  innervation.  Hysteri- 
cal paralysis,  and  that  occurring  after  overwork  or  excesses,  and  from 
nervous  exhaustion,  are  examples. 


DISEASES   OF  THE   BRAIN  AND  SPINAL   CORD.  91 

Paralysis  due  to  a  lesion  in  the  course  of  a  nerve. — The  nervous  force 
may  be  properly  generated,  but  the  nerve-fibres  may  be  incapable  of 
conductmg  it.  For  instance,  if  a  nerve  be  wounded  or  compressed, 
paralysis  of  the  muscles  which  it  supplies  takes  place.  Palsy  from 
this  cause  is  local,  and  is  apt  to  show  marked  nutritive  changes  in  the 
affected  part,  such  as  glossy  fmgers  and  swollen  joints,  and  to  be 
associated  with  pain. 

Paralysis  due  to  an  affection  of  the  nerves  at  their  exh-emities. — An 
illustration  of  such  a  disorder  is  the  palsy  resulting  from  exposure  to 
cold.  Peripheral  palsies  lead  quickly  to  atrophy  of  the  muscles. 
They  are,  from  their  very  nature,  local,  and  commonly  remain  so. 
But  many  peripheral  nerves  may  become  implicated,  and  extensive 
palsies  result,  as  seen  in  multiple  neuritis. 

Motor  paralysis  due  to  cold  may  be  met  with  as  a  family  affection. 
It  has  been  noticed  as  thus  happening  in  twenty-two  persons,  and  is 
clearly  described  by  Rich.^  On  exposure  to  cold  and  damp,  especially 
after  depressing  conditions,  the  muscles  become  fixed  and  immovable 
in  tonic  spasm.  Respiration,  cardiac  action,  cerebral  phenomena, 
and  sensibility  are  unchanged ;  the  muscles  of  deglutition  are  affected 
if  cold  substances  be  swallowed.  There  is  intense  desire  to  urinate, 
but  no  derangement  of  micturition  ;  the  sphincters  are  undisturbed. 
Motor  power  returns  gradually  and  progressively  on  exposure  to 
heat.  Recovery  is  followed  by  a  sense  of  exhaustion.  The  disease 
is  hereditary  through  many  generations.  It  affects  both  males  and 
females. 

Paralysis  due  to  serious  interference  with  the  circulation. — This  kind 
of  palsy  is  observed  if  the  principal  artery  of  a  part  be  obliterated. 
It  is  sometimes  noticed  as  a  transient  phenomenon  after  the  liga- 
tion of  a  large  artery.  If  the  vascular  supply  of  the  brain  be  inter- 
fered with' by  the  occlusion  of  a  vessel,  whether  by  embolism  or 
by  thrombosis,  the  hemiplegia  that  results  is  more  permanent  and 
very  marked.  Far  advanced  arteriosclerosis  may  also  be  among  the 
causes  of  palsy. 

Paralysis  due  to  a  morbid,  state  of  the  muscles. — It  is  douJDtful  if  it 
be  correct  to  call  that  paralysis  in  which  the  nervous  system  is  not 
primarily  or  particularly  concerned.  Yet  certain  forms  of  rheumatic 
palsy  and  of  muscular  atrophy  in  which  the  nervous  implication  is 
uncertain,  but  which  entail  loss  of  muscular  power,  may  be  mentioned 
here. 

A  loss  of  muscular  power  simulating  paralysis  is  seen  in  myasthenia 


^  Medical  News,  Aug.  25,  1894. 


92  MEDICAL  DIAGNOSIS. 

gravis  pseudopmxdytica,  the  designation  given  by  Jolly  ^  to  a  peculiar 
condition  characterized  by  undue  readiness  of  fatigue  of  voluntary 
muscles  after  ordinary  functional  activity.  In  fatal  cases  no  distinc- 
tive or  constant  lesion  has  been  found. 

Paralysis  due  to  the  "presence  of  poisons  in  the  system. — The  toxical 
effects  of  lead,  of  arsenic,  of  mercury,  of  alcohol,  and  of  sulphuret 
of  carbon,  may  exhibit  themselves  by  producing  palsy.  Malarial 
poison,  and  poisons  formed  in  the  system,  such  as  that  of  rheumatism 
or  of  gout,  may  act  in  the  same  way.  The  former  occasions  that 
singular  "  intermittent  paralysis"  which  may  come  on  either  as  one 
of  the  phenomena  of  a  fit  of  ague,  or  as  an  apparently  independent 
complaint,  which  may  assume  either  the  quotidian  or  tertian  type, 
and  in  which  both  sensation  and  motion  may  be  affected.  How  these 
poisons  operate,  whether  by  interfering  with  the  nutrition  of  the  ner- 
vous centres  and  weakening  their  generating  force,  or  by  enfeebling 
the  conducting  power  of  the  nerves,  or,  as  some  of  them  undoubtedly 
do,  by  setting  up  a  neuritis,  is  not  fully  determined.  The  palsies 
coming  under  this  head,  being  for  the  most  part  functional,  are  not 
ordinarily  intractable.  Those  due  to  malaria  show  the  malarial  cor- 
puscles in  the  blood,^  and  yield  speedily  to  decided  doses  of  quinine. 
Similar  to  the  palsies  of  poisons  and  certain  cachexias  are  the  palsies 
after  acute  diseases.  Yet  structural  changes  have  been  found  in  these 
paralyses  of  supposed  blood  origin,  and  many  of  them  are  owing  to 
neuritis. 

All  cases  of  periodic  paralysis  are  not  due  to  malaria ;  a  number  of 
instances  ha^e,  indeed,  been  recorded  which  were  not.^  They  are 
characterized  by  transitory  and  recurring  muscular  weakness  of  vary- 
ing degree  and  distribution,  but  without  other  constant  or  distinctive 
symptoms.  Sometimes  there  is  diminished  electric  irritability  of  the 
affected  muscles.  There  may  be  also  enfeeblement  of  the  reflexes, 
sensory  phenomena,  and  increased  thirst.  In  some  cases,  further,  a 
family  tendency  is  present.  In  a  thoroughly  studied  case  of  John  K. 
Mitchell's  five  instances  happened  in  the  mother's  family.  The  con- 
dition was  thought  to  be  autotoxic.^ 

In  paralyzed  parts  the  nutrition  and  secretion  are  disturbed  and 
the  circulation  is  sluggish  ;  they  are  frequently  swollen  and  (edem- 
atous, the    pulse    is  weaker  than   in  the    sound  members,  and  the 

^  Berliner  klinische  Wochenschrift,  1895,  No.  1,  p.  1. 
^  See  a  paper  published  by  me  in  the  International  Clinics,  1891,  vol.  iii. 
3  An  elaborate  study  of  this  subject  has  been  pubhshed  by  Taylor,   Journal 
of  Nervous  and  Mental  Diseases,  Sept.  and  Oct.  1898. 
*  Transactions  of  the  Assoc,  of  Amer.  Phys.,  1899. 


DISEASES   OF  THE  BRAIN  AND   SPINAL   CORD.  93 

sensation  may  be  impaired.  The  nails  grow  slowly,  so  do  the 
hairs ;  the  perspiration  is  defective ;  the  skin  feels  cold,  is  prone 
to  break  from  the  effect  of  pressure,  or  even  independently  of  it, 
and  the  ulcers,  if  they  heal  at  all,  heal  but  tardily.  The  condition  of 
the  muscles  varies.  In  some  cases  they  are  completely  relaxed,  in 
others  rigid ;  at  times  they  become  agitated  with  convulsive  move- 
ments. These  phenomena  are  most  evident  in  palsies  of  organic 
origin,  especially  in  those  dependent  upon  a  brain-lesion,  and  in  those 
due  to  disease  of  the  spinal  cord  in  which  anaesthesia  is  present. 
Where  hypersesthesia  occurs,  the  increased  sensibility  is  attended  with 
a  larger  supply  of  blood  and  a  higher  local  temperature. 

At  times  there  are  involuntary  movements  in  the  paralyzed  parts, 
associated  movements,  so-called  chorea  and  athetosis.  Thus,  in  cases 
of  hemiplegia  there  may  be  automatic  movements  in  the  palsied  arm 
when  the  patient  sneezes,  or  some  action  in  the  muscles  of  the  face  to 
cause  expressions  in  connection  with  the  motions  of  the  sound  side. 
Further,  rotation  of  the  head  and  neck  to  the  same  side  as  the  one  to 
which  the  eyes  are  directed — lateral  or  conjugate  deviation  of  the 
eyes — is  observed  to  be  peculiar ;  the  unopposed  muscles  turn  the 
head  and  eyes  towards  the  unparalyzed  side.  This  symptom  is  mostly 
transitory,  but  is  generally  found  in  sudden  hemiplegia. 

Let  us  now  inquire  into  the  mode  in  which  palsies,  no  matter 
what  their  origin,  are  investigated  at  the  bedside.  We  ascertain  the 
size,  appearance,  and  feel  of  the  stricken  part ;  take  notice  of  its 
growth  and  of  the  nutritive  changes,  such  as  alterations  in  look  and 
action  of  the  skin,  the  presence  on  it  of  eruptions  and  of  breaks,  the 
state  of  the  cutaneous  circulation,  of  the  nails,  the  hair,  and  the  joints. 
Then  we  test  the  sensibility  to  contact,  to  tickling,  to  pinching,  to  heat 
and  cold ;  measure  the  tactile  sense  by  the  aesthesiometer ;  ascertain 
the  muscular  sense ;  and  carefully  note  any  reflex  movements  that 
may  be  produced  in  the  apparently  lifeless  limb,  contrasting  them 
with  those  of  the  sound  limb,  and  determining,  also,  the  general 
state  of  this  as  to  muscular  force  and  sensation.  We  next,  where 
minuteness  of  investigation  is  desirable,  ascertain  the  surface  tempera- 
ture ;  and  pass  on  to  a  thorough  study  of  the  condition  of  the  mus- 
cles and  of  muscular  motion. 

Now,  in  examining  the  muscles  we  do  not  find  them  more  wasted 
than  their  disuse  will  account  for ;  certainly  not  in  palsies  of  cerebral 
origin.  Moreover,  we  generally  observe  them  to  be  flaccid, — rigidity, 
especially  early  rigidity,  being  rare ;  but  a  stiffening  associated  with 
pain  in  attempts  to  straighten  the  contracted  part  is  not  so  rare  where 
the  palsies  have  been  of  long  standing.     Then,  we  must  look  into  the 


94 


MEDICAL  DIAGNOSIS. 


degree  of  abolition  of  muscular  motion,  carefully  contrasting  it,  when 
one  sided,  with  the  movements  of  the  other  side.  Is  the  motion 
completely  abolished  or  only  impaired?  what  muscles  particularly 
are  affected  ?  are  concerted  movements  possible  or  is  there  incoordi- 
nation ?  and  is  the  gait  disturbed  ?  Moreover,  what  amount  of  mus- 
cular effort  is  required  to  overcome  special  resistance?  how  is  the 
balancing  power?  and  how  are  delicate  and  combined  movements 
executed  when  the  eyesight  is  withdrawn  ? 

When  the  power  in  the  arms  is  only  impaired,  not  lost,  we  ascer- 
tain the  degree  roughly  by  the  strength  of  the  grasp.  But  we  can 
do  so  accurately  by  a  dynamometer.  Of  these,  the  best  is  that  of 
Mathieu  (Fig.  13),  consisting  of  a  steel  ring,  slightly  elastic,  which  is 
pressed  firmly  in  the  hand  and  records  the  pressure. 

The  ability  of  the  patient  to  preserve  an  erect  position,  station, 
must  be  noted  as  well  as  the  degree  of  sivaying,  and  whether  he  does 
so  when  the  feet  are  brought  together  and  the  eyes  closed  (Romberg's 

Fig.  13. 


sign),  or  also  when  the  eyes  are  open,  which  bespeaks  a  much  higher 
degree  of  disorder.  The  normal  sway  with  the  eyes  open  is  in  adults 
about  half  an  inch  forward  and  backward,  and  three-quarters  of  an 
inch  laterally.     With  the  eyes  closed  it  is  much  greater. 

But  the  most  valuable  agent  by  which  to  judge  of  the  state  of  the 
-muscles  is  electriciti/,  especially  the  forms'  of  it  known  as  the  induced 
current,  or  "faradization,"  and  the  constant  current,  or  galvani- 
zation," and  the  action  of  each  must  be  separately  studied.  The 
parts  to  be  examined  should  be  in  similar  positions.  We  must  begin 
with  a  weak  current,  and  the  wet  electrodes  are  placed,  one  on  the 
muscle  itself,  the  other  on  some  other  part  of  the  muscle  or  some 
indifferent  point.  This  is  the  direct  excitation  of  the  muscle.  Or  the 
muscular  action  may  be  evoked  by  stimulating  the  motor  nerve  sup- 
plying the  muscle  to  be  tested.  This  is  indirect  excitation;  ^.nd  in 
healthy  nmscles  the  same  strength  of  current  will  produce  the  same 
amount  of  contraction  whether  muscle  or  motor  nerve  be  stimulated. 
It  is  also  important  to  break  the  current  by  slow  interruptions,  and, 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  95 

especially  in  employing  the  galvanic  current,  to  compare  the  positive 
(anodal)  and  the  negative  (cathodal)  opening  and  closing  contractions 
of  the  diseased  with  those  of  the  sound  side.  In  both  currents,  too, 
we  should  ascertain  what  the  c{uantitative  changes  are, — whether  the 
muscles  react  under  a  feebler  current  than  is  usual  or  require  one  of 
great  strength  to  move  them.  The  response  depends  upon  the  in- 
tegrity of  both  the  muscle  and  the  motor  nerve.  If  this  be  preserved, 
contraction  takes  place  with  every  change  in  a  current  of  sufficient 
force.  With  every  interruption  and  with  each  establishment  of  the 
current  the  muscle  can  be  seen  to  contract  in  health,  provided  the 
intervals  between  breaking  and  making  of  the  current  be  not  too 
short.  The  readiness  of  response  to  the  faradic  current  is  alike, 
whichever  pole  is  applied  to  the  muscle  or  nerve,  and  also  when  the 
current  is  made  and  broken ;  but,  with  the  galvanic  current,  the 
readiness  of  reaction  varies  both  with  the  electrode  used  and  with 
the  making  and  breaking  of  the  current. 

Diminished  or  lost  electro-muscular  cont7^actility  is  a  most  valuable 
sign  in  destructive  diseases  of  the  cord.  Indeed,  speaking  in  general 
terms,  we  may  say  that  it  belongs  to  spinal  palsies,  while  the  electro- 
muscular  contractility  is  intact  in  cerebral  palsies.  But  this  is  only 
true  of  spinal  palsies  when  the  muscles  are  separated  entirely  from 
the  influence  of  the  cord :  those  supphed  by  nerves  having  their 
origin  in  healthy  spinal  texture  preserve  their  normal  irritability.  In 
fact,  if  the  uninjured  part  of  the  cord  have  become  irritated,  or  more 
vascular,  the  muscles  having  a  nervous  connection  with  it  may  show 
increased  susceptibility  to  the  electric  current,  and  more  energetic 
contraction.  We  also  fmd  diminished  electro-muscular  contractility 
when  the  nerve  itself  is  injured ;  when  there  is  a  mere  local  change 
in  the  muscular  texture  of  the  helpless  part ;  and  as  the  result  of 
certain  poisons,  as  of  opium,  lead,  rheumatism,  or  other  blood- 
poisons,  which  lower  the  power  of  nerve,  of  muscle,  or  of  nerve- 
centre.  We  find  it  also  when  there  has  been  long  disuse  of  a  limb, 
as  in  old  cases  of  hysterical  palsy,  and  even  of  cerebral  palsy.  But 
this  is  temporary,  not  permanent ;  for  using  the  battery  for  a  few 
days  makes  the  greatest  change  in  the  electro-muscular  contractility. 

As  already  stated,  the  electro-muscular  contractility  is  normal  in 
the  forms  of  palsy  due  Ho  brain  disease.  The  palsied  limb  may  have, 
indeed,  its  muscles  more  powerfully  convulsed  by  a  current  of  the 
same  •  intensity  than  those  of  the  sound  side  are,  and  then  we  may 
infer,  as  Todd  ^  and  Althaus  ^  have  shown,  that  the  paralysis  is  due  to 

^  Clinical  Lectures  on  the  Nervous  System.  ^  Medical  Electricity. 


96  MEDICAL  DIAGNOSIS. 

brain  disease  of  an  irritative  character.  In  recent  hemiplegias,  what- 
ever their  origin,  increase  of  electric  excitability  is  not  uncommon. 
The  response  of  muscle  to  faradic  stimulation  is  called  faradic  exeita- 
hility ;  and  the  remarks  made  are  based  on  the  effects  obtained  by 
faradization. 

With  reference  to  the  galvanic  or  continuous  current,  or  galvanic 
excitability,  we  find  that  in  a  healthy  state  of  the  muscles  the  galvanic 
current  will  give  the  same  results  as  faradization,  whether  muscle 
itself  or  its  motor  nerve  be  acted  on.  Healthy  muscle  and  nerve 
react  most  readily  to  galvanic  stimulation  when  the  negative  pole  is 
applied  and  the  current  is  made,  and,  successively,  when  the  positive 
pole  is  applied  and  the  current  is  either  broken  or  made,  and,  finally, 
when  the  negative  pole  is  applied  and  the  current  is  broken.  This  so- 
called  "normal  formula"  may  be  represented  graphically  as  follows: 

K.Cl.C.  'A        r\  n    '  K.O.C. ;  in  which  K  (cathode)  stands  for  the  nega- 
te A.n.U.U.  I 

five  pole,  An  (anode)  for  the  positive  pole,  CI  (closure)  for  the  making, 
and  0  (opening)  for  the  breaking  of  the  current,  and  C  for  the  mus- 
cular contraction.  In  diseased  conditions  galvanism  may  show  the 
same  or  it  may  show  different  reactions  from  faradism.  The  muscles 
of  a  palsied  part  may  respond  actively  to  galvanization  and  not  at  all 
to  faradization.  We  observe  this  when  the  muscular  tissue  has  be- 
gun to  atrophy  and  to  degenerate  in  consequence  of  extensive  lesions 
of  the  cord,  in  degenerative  affections  of  the  motor  roots,  in  trau- 
matic nerve  lesions,  and  in  diseases  of  the  peripheral  nerves.  While 
the  faradic  excitability  declines  or  is  lost,  the  galvanic  excitability 
not  only  remains,  but  may  be  even  exaggerated  ;  and  in  this  "  reaction 
of  degeneration"  (De.  R.)  there  are  also  complete  changes  in  the 
normal  laws  of  electric  muscular  contraction ;  the  anodal  closing 
contraction  equals  or  even  exceeds  the  cathodal  closing  contraction, 
the  cathodal  opening  contraction  declines  in  the  same  manner. 
There  is  a  deviation  from  the  normal  order  of  response,  and  thus  we 
note  qualitative  and  not  merely  quantitative  modifications.  Again, 
we  may  find  dissimilarities  by  interrupting  the  galvanic  current,  and 
these  may  vary  whether  the  current  be  rapidly  or  slowly  broken. 
Thus,  Russell  Reynolds  has  shown  us  that  in  certain  instances  of 
facial  palsy  from  exposure  to  cold,  or  in  paralysis  of  the  limbs  from 
the  same  cause,  or  in  lead  palsy,  the  muscles  act  as  little  under  the 
rapidly  interrupted  galvanic  current  as  under  faradization  ;  but  if  the 
galvanic  current  be  slowly  interrupted,  they  exhibit  a  greater  amount 
of  irritability  than  do  the  healthy  muscles.  In  these  cases  it  is  found 
that  the  muscles  are  primarily  affected,  and  the  application  of  slowly 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  97 

interrupted  galvanism  is  rapidly  of  much  service.  It  is,  indeed,  well 
in  all  cases  of  palsy,  whatever  be  the  form  of  battery  employed,  to 
note  the  differences  in  the  contraction  of  the  muscles  produced  by 
slow  or  by  rapid  interruptions.  Static  or  Franklinic  electricity  may 
also  be  employed  for  purposes  of  diagnosis.  We  meet  with  instances 
where  muscles  contract  under  its  use  which  do  not  respond  to  either 
the  faradic  or  the  galvanic  current.^ 

As  already  stated,  a  muscle  may  be  indirectly  acted  on  ;  one  mois- 
tened electrode  is  placed  over  the  motor  nerve  which  controls  the 
muscle,  the  other  over  its  body.  In  inflammation  of  the  nerve  irrita- 
bility of  the  muscle,  both  galvanic  and  faradic,  is  increased ;  in  de- 
structive injuries  it  lessens  and  disappears.  It  is  always  well  to  note 
the  indirect  as  well  as  the  direct  muscle  excitation.  But  it  has  not, 
for  purposes  of  diagnosis,  proved  itself  as  generally  valuable.  We 
should  endeavor  to  place  the  one  or  other  of  the  sponges  exactly  over 
the  seat  of  chief  nerve-supply  in  the  muscle ;  and  the  ascertainment 
of  the  nerve  point  or  points  that  correspond  with  the  entrance  of  the 
motor  nerves  into  the  muscles  has  been  made  a  matter  of  much  study. 
Experience,  indeed,  proves  that  from  these  motor  points,  determined 
with  infinite  care  and  labor  by  Ziemssen,  knowledge  now  accessible 
in  any  work  on  medical  electricity,  and  in  most  on  nervous  diseases, 
the  readiest  control  of  the  muscles  is  obtained. 

When  the  muscles  react  under  electricity  the  contraction  is  felt, 
and  the  ''  electro-muscular  sensibility"  is  more  decided  the  stronger 
the  contraction.  Hence  we  almost  always  find  increased  electro-mus- 
cular contractility  with  increased  electro-muscular  sensibility.  But 
the  latter  may  exist  alone,  as  we  mostly  observe  in  myalgias.  On  the 
other  hand,  the  relationship  between  diminished  contractility  and  sen- 
sibility may  be  changed,  as  we  find,  for  instance,  in  the  striking  want 
of  sensibility  to  the  current  in  hysterical  paralysis.  The  electric  re- 
actions of  the  skin,  well  tested  by  a  metallic  brush,  as  a  rule  go  hand 
in  hand  with  the  reactions  of  the  muscles,  increase  in  sensitiveness 
with  them,  decrease  with  them. 

Such  are  the  chief  facts  with  reference  to  the  diagnostic  applica- 
tions of  electricity  in  paralysis.  There  is  yet  another  mode  of  inves- 
tigation which  we  constantly  bring  into  use,  one  also  in  which  the 
action  of  the  muscles  particularly  gives  us  valuable  information  con- 
cerning the  state  of  the  nervous  system, — the  testing  of  the  reflex 
excitability.     But  we  have  already  examined  into  the  derangement  of 

^  See  an  excellent  summary  of  the  diagnostic  value  of  Franklinic  electricity 
by  Bernhardt,  Samml.  Klin.  Vort.,  No.  41,  Feb.  1892. 


98  MEDICA-L  DIAGNOSIS. 

the  reflex  system,  and  shall  only  add  here  a  few  general  clinical  facts. 
We  find  the  reflex  excitability  diminished  in  disease  of  the  gray  sub- 
stance of  the  cord,  in  disease  of  the  sensory  root-fibres,  which  thus 
become  incapable  of  conducting  the  impression,  and  in  disease  of  the 
motor  fibres,  which  fail  to  impart  the  motor  impulse.  In  the  latter 
case  there  is  coexisting  paralysis  of  motion ;  in  the  second,  anses- 
thesia.  Increase  of  reflex  excitability,  producing  twitching  or  even 
violent  irregular  movement  on  very  slight  stimulation,  is  found  in  all 
irritative  lesions  which  have  increased  the  excitability  of  the  gray 
substance  of  the  cord ;  as  when  this  is  disturbed  by  inflammation,  or 
compressed  by  a  tumor,  or  heightened  by  certain  drugs,  such  as 
strychnine.  Increase  of  reflex  excitability  is  also  found  in  parts 
below  a  lesion,  when  this  gives  rise  to  descending  degeneration  in 
the  pyramidal  tracts. 

As  regards  the  action  of  the  brain,  there  are  instances  in  which, 
if  all  power  of  appreciating  impressions  be  lost,  as  in  overwhelming 
cerebral  apoplexies,  reflex  action  may  be  everywhere  suspended.  On 
the  other  hand,  irritation  transferred  from  diseased  to  healthy  parts 
of  the  brain  may  produce  spasms  or  palsy  phenomena ;  or  the  reflex 
actions  may  be  excited  in  other  parts  of  the  body,  as  the  muscular 
contractions  in  the  legs  during  catheterization  or  in  colics.  Here  the 
seat  of  the  perverted  reflex  action  is  entirely  in  the  reflex  areas  of 
the  cord. 

All  these  remarks  tell  us  how  to  examine  paralysis.  Having  now 
studied  the  modes  in  which  this  is  investigated,  I  shall  merely  recall 
that  to  find  out  the  cause  of  the  difficulty  we  have  to  take  into  ac- 
count the  history  of  the  case,  and  the  attending  symptoms,  nervous 
and  otherwise  ;  and  in  eliciting  these  we  should  never  forget  to  bring 
out  prominently  those  shown  us  by  the  opthalmoscope,  and  by  ex- 
amination of  the  urine  and  of  the  heart. 

Let  us  proceed  to  the  clinical  study  of  palsies. 

HEMIPLEGIA. 

We  shah  first  consider  that  form  which  almost  always  results  from 
brain  disease, — hemiplegia,  or  one-sided  palsy.  This  state  of  things 
may  affect  all  the  voluntary  muscles  on  one  side  of  the  body  ;  but  it 
generally  exists  only  in  those  of  the  limbs  and  face  ;  the  eye,  neck, 
and  trunk  muscles  escape  largely,  though  not  entirely.  Neither  the  legs 
nor  the  arms  can  move,  and  the  muscles  of  the  face  on  the  side  cor- 
responding to  the  paralyzed  limbs  are  motionless.  The  cheek  hangs  ; 
the  mouth  is  drawn  towards  the  healthy  side,  because  the  muscles 
on  the  other  are  powerless  to  resist ;  the  tongue,  when  protruded,  is 


DISEASES  OF  THE  BRAIN  AND  SPINAL   COBD.  99 

ordinarily  slowly  pushed  out  towards  the  palsied  side  ;  the  articula- 
tion is  imperfect. 

But  the  rule  with  respect  to  the  face  being  paralyzed  on  the  same 
side  as  the  rest  of  the  body  has  its  exceptions.  Should  the  lesion  be 
seated  in  the  brain,  above  the  crossing  of  the  facial  nerves,  both  face 
and  body  are  paralyzed  on  the  side  opposite  to  the  diseased  spot. 
Should,  however,  the  lesion  involve  the  facial  nerve-fibres  at  a  point 
below  or  after  their  decussation,  there  will  be  paralysis  of  the  face  on 
one  side  and  the  limbs  on  the  other,  the  facial  palsy  being  direct, 
and  that  of  the  body  being  crossed. 

Now,  according  to  Gubler,  this  cross  paralysis  is  always  indicative 
of  a  lesion  of  the  pons  Varolii,  close  to  which  the  facial  nerves  origi- 
nate, and  through  which  the  nerve-fibres  for  the  limhs  pass  before 
they  decussate  lower  down.  But  we  must  remember  that  there  are 
rare  cases  of  "  alternating  hemiplegia,"  clue  to  a  combination  of 
lesions,  one  affecting  a  cerebral  lobe  on  one  side  and  the  facial  nerve 
on  the  other.  Even  when  the  lesion  is  unilateral,  we  may  meet  with 
exceptional  cases  ;  and,  as  Bastian  ^  points  out,  the  lesion  may  be  sit- 
uated in  the  pons,  the  palsy  of  face  and  limbs  not  being  alternate, 
provided  the  disease  occur  in  the  upper  or  anterior  part  of  one  lateral 
half,  implicating  the  fibres  of  the  facial  above  their  sites  of  decussa- 
tion. With  reference  to  the  other  cerebral  nerves,  should  we  find 
any  of  them  paralyzed  on  one  side  and  the  body  on  the  other,  we 
shall  generally  be  correct  in  assuming  that  the  palsy  is  not  due  to  dis- 
ease on  both  sides  of  the  brain,  but  is  rather  a  disturbance  of  the 
affected  nerve  near  its  origin  or  in  its  course,  and  on  the  side  on  which 
the  brain  is  injured,  while  the  paralysis  of  the  limbs  is  on  the  oppo- 
site side.  Anatomical  researches  which  have  traced  connecting  nu- 
clei on  the  floor  of  the  fourth  ventricle  and  elsewhere  explain  these 
alternating  palsies. 

Hemiplegia,  as  already  stated,  results,  in  the  vast  majority  of  in- 
stances, from  cerebral  diseases.  Hence  we  find  it  commonly  associ- 
ated with  disordered  mental  powers,  and  other  signs  of  a  brain  lesion. 
The  superficial  reflexes  are,  as  a  rule,  though  not  invariably,  dimin- 
ished ;  the  deep  reflexes  are  exaggerated.  The  rectum  and  the  blad- 
der perform  their  functions.  The  non-paralyzed  side  is  not  wholly  free . 
from  signs  of  disorder.  Mills  ^  has  given  us  an  interesting  study  of 
its  condition,  and  we  see  that  considerable  loss  of  power  and  associ- 
ated movements  with  any  on  the  paralyzed  side  are  common, 

^  Paralysis  from  Brain  Disease. 

^  The  Nervous  System  and  its  Diseases,  1898. 


100  MEDICAL  DIAGNOSIS. 

Hemiplegia  caused  by  an  affection  of  one-half  of  the  spinal  cord, 
near  its  beginning,  is  not  combined  with  a  decay  of  the  mental  facul- 
ties, but  the  muscles  of  the  chest  and  abdomen  are  involved  in  the 
paralysis,  which  they  are  not  in  cerebral  hemiplegia,  unless  the  lesion 
be  very  extensive.  Then  in  spinal  hemiplegia  there  is  a  zone  of  an- 
aesthesia on  a  level  with  the  lesion,  and  coexisting  auEesthesia,  as 
Brown-Sequard  has  shown,  on  the  side  opposite  to  the  lesion  and  the 
muscular  palsy,  and  the  temperature  sense  is  impaired,  as  is  the  sen- 
sLlDility  to  pain ;  the  palsied  limb  gives  evidences  of  vasomotor  paral- 
ysis, has  at  first  a  higher  temperature,  and  is  hypersesthetic ;  reflex 
action  is  increased  on  the  side  of  the  lesion,  the  muscular  sense  is 
impaired,  and  the  umbilicus  is  with  every  act  of  inspiration  drawn 
towards  the  sound  side.  We  possess  a  further  test  in  electricity : 
unlike  what  we  find  in  cerebral  paralysis,  the  electro-muscular  con- 
tractility is  greatly  lessened  or  is  lost.  Spinal  hemiplegia,  or  "  hemi- 
paraplegia,"  as  it  is  more  often  called  if  the  lesion  be  low  down, 
occurs  from  injuries,  tumors,  syphilitic  disease  of  the  cord,  and  local- 
ized sclerosis.  Spinal  hemiplegia  is  more  persistent  in  the  leg  than 
it  is  in  the  arm.  In  hemiplegia  due  to  cerebral  disease  recovery  is 
more  rapid  and  more  nearly  perfect  in  the  leg  than  in  the  arm. 

But  supposing  that  we  have  settled  the  hemiplegia  to  be  cerebral, 
the  points  next  to  be  investigated  are,  where  is  the  lesion  situated  ? 
and  what  is  its  nature  ?  Now,  the  former  question,  concerning  the 
anatomical  diagnosis,  may  be  answered  in  a  general  way  by  stating 
that  the  disease  is  on  the  side  opposite  to  the  palsy,  if  the  lesion,  as 
it  almost  always  is,  be  seated  above  the  point  of  decussation  of  the 
pyramidal  columns  of  the  medulla ;  for  a  lesion  below  the  decussa- 
tion gives  rise  to  palsy  on  the  same  side,  and  a  lesion  on  a  level  with 
it,  to  double-sided  palsy.  Lesions  of  the  posterior  segment  of  the  in- 
ternal capsule  give  rise  to  typical  hemiplegia,  sometimes  with  hemian- 
sesthesia  and  loss  of  the  special  senses.  Lesions  of  the  corpus  striatum 
cause  motor  and'  sensory  symptoms  only  when  they  involve  the  in- 
ternal capsule.  The  same  is  true  of  disease  of  the  optic  thalamus, 
except  that  mobile  spasm  and  incoordination  of  movement  have  been 
observed  to  follow  lesions  of  its  middle  third. 

The  nearer  the  lesion  to  the  surface,  the  more  marked  are  the 
mental  phenomena,  the  greater  is  the  tendency  to  spasms  in  the 
limbs,  but  the  more  limited  is  the  palsy ;  and  the  farther  the  disease 
extends  towards  the  internal  capsule,  the  more  extensive  does  the 
paralysis  of  motion  become.  We  may  further  distinguish  the  palsy 
which  ensues  from  that  caused  by  an  affection  lower  down,  as  of  the 
pons  Varolii,  by  observing  that,  besides  the  peculiar  crossed  paralysis 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  101 

of  the  face  and  limbs,  we  find  giddiness  and  a  tendency  to  vomit ;  either 
loss  of  the  conjugate  movement  of  the  eyes  towards  the  side  of  the 
lesion,  or  conjugate  spasm  with  nystagmus ;  jerkings  of  the  muscles 
of  the  face  on  the  side  opposite  to  the  injury  ;  sensations  of  tickling  in 
the  face ;  one-sided  facial  anaesthesia,  with  a  loss  of  sense  of  taste  on 
the  corresponding  side,  though  with  unimpaired  motion  of  the  tongue  ; 
rigidity  of  the  limbs,  and  spasm  of  the  muscles  supplied  by  the  fifth 
nerve ;  disturbance  of  respiration  and  of  the  heart ;  albuminuria ; 
glycosuria ;  high  temperature.  Should  we  encounter  paralysis  of 
sensibility  and  motion  on  one  side  of  the  body,  and  both  sides  of  the 
face  be  palsied  as  to  motion  and  sensation ;  should  the  recti  muscles 
of  the  eye  be  paralyzed,  and  taste  be  lost  over  the  anterior  part  of  the 
tongue,  we  may  infer  that  the  injury  is  seated  rather  above  the  lower 
portions  of  the  pons,  and  affects  the  spot  where  the  facial  nerve  and 
part  of  the  trigeminal  cross.^  Hyperpyrexia  is  not  uncommon  after 
the  onset  of  an  acute  lesion  of  the  pons,  and  in  acute  lesions  convul- 
sions^ are  also  usual,  as  is  marked  contraction  of  the  pupils.  In 
lesions  mvolving  the  central  parts  of  the  pons,  paralysis,  mostly  un- 
equal, of  both  sides  of  the  body,  with  impaired  sensation,  irregular 
facial  palsy,  difficulty  in  deglutition  and  articulation,  is  the  rule. 

Lesions  of  the  lower  and  inner  part  of  the  cms  cerebri  are  recog- 
nized by  an  alternate  paralysis,  in  which  the  third  nerve  is  palsied  on 
the  affected  side  of  the  brain,  showing  us  want  of  action  of  the  mus- 
cles of  the  eyeball,  except  the  external  rectus  and  superior  oblique, 
ptosis,  a  dilated  pupil,  a  tongue  deviating  to  the  paralyzed  side,  some 
difficulty  in  articulation,  the  palsy  marked  in  the  arm  and  leg,  and 
coexisting  with  increased  local  temperature,  vasomotor  disturbance, 
and  very  defective  sensation. 

Acute  lesions  of  the  medulla  are  likely  to  destroy  life ;  in  case 
they  do  not,  the  resulting  symptoms  are  often  bilateral  and  include 
derangement  of  the  functions  of  the  bulbar  nerves. 

Besides  these  well-attested  facts,  the  brilliant  researches  of  the  day 
on  the  localization  of  cerebral  functions  have  solved,  and  are  still 
solving,  many  problems  as  important  to  the  physician  as  to  the  physi- 
ologist. Let  us  look  at  some  of  the  additions  to  pathological  knowl- 
edge which  appear  the  most  certain,  premising  that  in  localization 
only  symptoms  that  are  permanent  are  of  value,  since  any  lesion,  an 
acute  lesion  especially,  may  for  the  time  being  cause  vascular  or  in- 
hibitory disturbance  in  adjacent  parts.     We  must  also  be  mindful  of 

^  Brown-Sequard,  Dublin  Quarterly  Journal,  May,  1865. 
^  Gowers,  Diseases  of  the  Nervous  System. 


102  MEDICAL   DIAGNOSIS. 

Broadbent's  law,  that  one-sided  movements  can  be  excited  from  either 
hemisphere,  and  that  the  loss'  may  be  soon  compensated  by  the  hemi- 
sphere with  which  they  are  not  habitually  associated.  This  becomes 
often  manifest  in  damages  of  the  cortex. 

We  shall  first  glance  at  lesions  of  the  motor  zone,  including  the  as- 
cending frontal  and  parietal  convolutions,  the  anterior  two-thirds  of 
the  superior  parietal  lobule  and  paracentral  lobule,  parts  supplied  by 
branches  of  the  middle  cerebral  artery.  A  lesion  of  these  cortical 
structures  causes  paralysis  of  motion  without  marked  loss  of  sensation. 
The  hemiplegia  is  more  or  less  complete  according  to  the  extent  of 
the  motor  area  involved.  It  is  on  the  opposite  side  to  that  of  the 
disease,  and  neither  the  nutrition  nor  the  electric  contractility  of  the 
palsied  muscles  is  impaired. 

The  cortical  hemiplegia,  when  sudden,  is  less  frequently  accompa- 
nied by  loss  of  consciousness,  is  rarely  complete  from  the  first,  affect- 
ing, perhaps,  at  the  onset  only  the  face,  an  arm,  or  a  leg,  and  is  soon 
followed  by  rigidity  of  the  palsied  parts.  It  is  apt  to  be  transitory,  to 
show  slighter  differences  in  temperature  between  the  two  sides,  and 
to  be  accompanied  by  localized  pain  in  the  head,  which  may  be 
elicited  by  percussion  over  the  seat  of  the  lesion,  and  by  temporary 
aphasia.^  There  is  no  impairment  of  sensation  in  lesions  of  the 
motor  cortex.^  Limited  palsies,  monoplegias,  are  much  more  com- 
mon in  disease  of  the  cortex  than  in  disease  of  deeper  parts.  The 
leg  alone  is  affected  in  lesions  of  the  medial  cortex  or  those  near  to 
the  longitudinal  fissure.  Irritative  lesions  of  the  cortex  have  as  their 
most  characteristic  sign  unilateral  convulsions.  In  disease  of  the 
middle  third  of  the  central  convolutions  the  convulsions  generally 
begin  in  the  hand.  Disease  of  the  ascending  frontal  convolution, 
behind  the  inferior  frontal,  gives  rise  to  paralysis  of  the  face,  lips,  and 
tongue. 

Lesions  confined  to  any  one  of  the  gray  central  ganglia,  where  the 
internal  capsule  is  not  involved,  do  not  afford  any  special  feature  by 
which  they  may  be  distinguished  from  common  cerebral  hemiplegia. 
There  is  paralysis  of  motion  only,  which,  Charcot^  tell  us,  is  gener- 
ally transitory.  If  the  anterior  two-thirds  of  the  posterior  limb  of 
the  internal  capsule  be  involved,  the  palsy  is  still  exclusively  of  mo- 
tion, though  it  is  more  or  less  persistent,  and  ultimately  accompanied 
by  muscular  contractions  ;  if  the  posterior  third  be  also  involved,  we 


^  Ferrier,  Localization  of  Cerebral  Disease. 

■^  Mills,  The  Nervous  System  and  its  Diseases,  1898. 

^  Lectures  on  Localization  in  Diseases  of  the  Brain,  New  York,  1878. 


DISEASES  OF  THE  B^AIN  AND  SPINAL   CORD.  103 

have  in  addition  cerebral  hemiansesthesia.  Smell  may  also  be  lost  on 
the  anaesthetic  side,  and  hemianopsia  be  met  with.  In  disease  of  the 
angle  and  posterior  segment  of  the  internal  capsule  we  have  hemi- 
plegia of  the  ordinary  type.  Indeed,  in  lesion  of  the  corpus  striatum 
the  hemiplegia  is  permanent  only  if  the  internal  capsule  be  involved 
in  the  damage. 

A  lesion  of  one  optic  tract  or  of  the  cortical  visual  centre  in  the 
occipital  lobe  will  'cause  bilateral  homonymous  hemianopsia ;  a  simi- 
lar effect  is  sometimes  produced  by  a  lesion  of  the  corpora  geniculata 
on  one  side.  There  may  be  considerable  hebetude,  but  no  other 
marked  symptom  of  an  affection  of  the  brain  except  hemianopsia. 
In  lesions,  also,  of  the  prcefrontal  lobes,  that  part  which,  in  its  relation 
to  the  skull,  is  roughly  bounded  by  the  coronal  suture,  there  is  no 
disorder  either  of  motility  or  of  sensibility.  The  manifestations  are 
simply  those  of  restlessness  and  unsteadiness  of  mind,  mental  apa- 
thy, impairment  of  judgment  and  reason,  and  other  psychical  disturb- 
ances ;  a  tendency  io  make  jokes  has  also  been  noted.^  Yet  the 
frontal  lobes  of  one  side  may  be  totally  destroyed  without  changes  in 
mind  or  character.^  There  is  no  motor  paralysis  except  of  the  foot. 
■Late  in  the  case,  among  pressure  and  invasion  symptoms,  we  may . 
find  motor  aphasia,  nystagmus,  and  unilateral  convulsions.^  In  dis- 
ease of  the  tem])oro-sphenoidal  lobe  we  have  deafness  in  the  ear  oppo- 
site to  the  lesion,  if  left-sided  sensory  aphasia,  and  sometimes  con- 
vulsions with  preceding  auditory  aura.     There  is  no  hemiplegia. 

The  nature  of  the  paralyzing  lesion,  the  pathological  diagnosis,  can 
be  arrived  at  only  by  a  careful  scrutiny  of  all  the  facts  of  the  case. 
A  sudden  paralysis  occurring  simultaneously  with  coma  almost  always 
has  its  origin  in  an  apoplectic  effusion,  more  rarely  in  cerebral  em- 
bolism or  thrombosis.  A  sudden  paralysis  without  coma  is  generally 
due  to  plugging  of  the  vessels.  A  gradual  development  of  palsy  in- 
dicates some  chronic  cerebral  disease,  such  as  chronic  endarteritis 
with  altered  brain  nutrition,  or  a  tumor,  or  any  affection  compressing 
the  nervous  substance.  'We  may  also  gain  much  knowledge  by  care- 
fully exploring  the  organs  of  circulation  and  the  kidneys.  Thus,  a 
paralysis  found  to  be  conjoined  to  a  cardiac  malady  or  to  a  diseased 
state  of  the  arteries  is,  in  all  likelihood,  owing  to  a  clogging  of  one  of 
the  cerebral  arteries,  and  to  consecjuent  tissue-change  in  the  cere- 
bral  structures.     When   the   kidneys   are   seriously   disordered,   the 


^  Oppenheim,  "  Geschwulste  des  NeiTensystem,"  in  Nothiiagers  System. 
^  Case  of  Bailey,  "  Hemiatrophy  of  the  Brain,"  Amer.  Journ.  Med.  Sci.,  March, 
1899. 

^  Mills,  Cerebral  Localization  in  its  Practical  Relations,  1889. 


104  MEDICAL  DIAGNOSIS. 

hemiplegia  is  likely  to  be  caused  by  some  chronic  disease  of  the  brain 
or  its  vessels,  the  result  of  an  altered  nutrition.  The  urgemic  con- 
dition itself  seems  also  capable  of  causing  loss  of  power,  sometmies 
of  hemiplegic  tj^e. 

In  paralyzed  limbs  we  are  apt  to  meet  T\ith  rigid  states  of  the 
muscles  due  to  tonic  spasm,  which,  when  they  produce  spastic  mus- 
cular shortening,  are  called  contractures.  Under  ether  or  chloro- 
form angesthesia  these  disappear.  When  the  paralyzed  limbs  exhibit 
a  rigid  state  from  the  moment  of  or  soon  after  the  attack,  the  early 
rigidity  pomts  to  an  irritative  lesion,  such  as  a  compression  of  healthy 
brain-tissue  by  an  apoplectic  clot.  Late  rigidity,  if  persistent,  generally 
becomes  associated  with  wasting  of  the  muscles,  and  with  central  de- 
generation of  the  motor  tracts.  It  is  generally  combined  with  excessive 
tendon  reflexes,  muscle  jerk,  and  \\\i\\  ankle  clonus.  Under  excite- 
ment the  paralyzed  arm  and  leg  may  be  strongly  flexed,  and  automatic 
movements  may  occur  when  the  patient  sneezes.^  We  may  also  on  the 
palsied  side  meet  with  tremors  ;  mth  attacks  of  true  spasms,  happen- 
ing particularly  in  the  arms  ;  ^^ith  joint-disease  and  nodes  ;  and  with 
choreic  movements,  a  condition  to  which,  under  the  name  of  "  post- 
paralytic chorea,"  Weir  Mitchell  -  has  called  attention.  In  some  cases 
of  hemiplegia  there  is  much  pain  in  the  stricken  limb.  The  pain" 
may  precede  returning  motion,  and  is  thus  of  favorable  augury.  But 
in  limited  disease  of  the  internal  capsule  affecting  the  sensory  path 
the  pain  in  the  palsied  Imibs  may  persist  through  life.  In  old  hemi- 
plegias the  surface  temperature  is  lower  than  on  the  non-paralyzed 
side. 

Hemiplegia  may  be  feigned.^  But  the  results  of  electricity,  espe- 
cially where  altered  sensibility  as  well  as  defective  motion  is  smiu- 
lated,  and  the  test  proposed  by  Hughlings  Jackson,  that  the  arms  do 
not,  as  in  real  hemiplegia,  fall  forward  when  the  patient  stoops,  but 
are  retained  at  the  side,  will  usually  detect  the  fraud. 

MOXOPLEGIA. 
When  we  have  limited  lesions  we  have  hmited  palsies,  and  re- 
searches on  localization  are  teacliing  us  more  and  more  accurately  to 
recognize  the  centres  affected  in  these  palsies  of  special  parts,  or  of 
one  limb,  or  of  a  group  of  movements.  Of  course,  in  making  a  diag- 
nosis of  the  paralysis  being  due  to  disturbance  of  a  special  nerve- 

^  Ross,  Diseases  of  the  Nervous  System,  1883,  vol.  i.  p.  187. 

=^  Amer.  Journ.  Med.  Sci.,  Oct.  1874:  also  Med.  News,  April,  1893. 

^  For  an  instructive  case  see  London  Lancet,  April,  1874. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  105 

centre,  we  must  be  careful  to  exclude,  as  the  cause  of  the  local  palsy, 
peripheral  affections,  and  those  in  the  course  of  the  nerve  supplying 
the  stricken  part,  and  also  to  make  it  clear  that  the  lesion  is  not 
spinal  of  very  circumscribed  kind.  In  monoplegias  the  palsy  is  never 
complete.  Furthermore,  it  is  always  important  in  a  given  case  to 
separate  the  symptoms  which  may  be  due  to  invasion  of  or  to  press- 
ure on  adjacent  centres  from  the  localizing  symptoms  of  the  main 
lesion.  Let  us  now  take  up  some  of  the  limited  palsies  dependent 
on  cerebral  disease,  especially  in  the  motor  areas  of  the  cortex. 

One  arm  only  is  paralyzed. — Here  we  find  the  lesion  in  the  as- 
cending parietal  and  the  ascending  frontal  convolution  on  the  side 
opposite  to  the  palsy,  and  the  disease  is  limited  to  the  middle  third  of 
the  convolutions.  If  the  lesion  be  double,  as  in  a  case  referred  to  by 
Bourdon,^  both  arms  are  helpless.  But,  whether  single  or  double, 
with  the  damaged  motion  there  are  unimpaired  sensation  and  electro- 
motor contractility.  Disease  of  the  ascending  frontal  opposite  the 
upper  half  of  the  inferior  frontal  convolution  gives  rise  to  palsy  of 
the  lower  part  of  the  face  except  the  lips. 

One  arm  and  the  same  side  of  the  face  are  paralyzed. — In  this 
"  brachio-facial  monoplegia"  the  lesion  is  in  the  central  region  of  the 
cortex,  towards  the  middle  or  lower  third  of  the  ascending  convolu- 
tions in  the  facial  and  arm  centres.  It  is  a  purely  motor  palsy,  asso- 
ciated, however,  usually  with  aphasia  when  the  disease  is  left-sided. 
The  main  movements  of  the  muscles  of  the  upper  part  of  the  arm 
are  kept,  while  those  of  the  hand  are  lost.  Palsy,  of  cerebral  origm, 
limited  to  one  side  of  the  face,  without  the  arm  being  implicated,  is 
rare ;  the  cortical  disease  is  in  the  centre  for  the  facial  region.  The 
affection  is  usually  left-sided,  and  is  apt  to  become  complicated  with 
aphasia.  The  lower  part  of  the  face  bears  the  brunt  of  the  palsy ; 
unlike  Bell's  palsy,  the  orbicularis  and  the  upper  part  of  the  face  are 
but  little,  if  at  all,  disturbed  ;^  further,  there  is  no  disease  of  the  tem- 
poral bone  to  explain  the  localized  palsy  by  an  injury  to  the  facial 
nerve.     The  tongue  is  also  very  generally  implicated. 

The  leg  only  is  paralyzed. — This  is  a  very  rare  form  of  paralysis, 
and  presupposes"  a  lesion  limited  to  the  motor  centre  for  the  leg. 
The  centre  for  the  leg  and  foot  is  fixed  by  the  researches  of  Horsley . 
and  Schaefer  as  occupying  the  uppermost  portion  of  the  ascending 
frontal  and  parietal  convolutions.     In  some  of  these  cases  of  "  crural 


iBull.  Soc.  Anat.,  1874. 
.^  This  is  strikingly  illustrated   in  a  case   reported  by  Guiteras,   Phila.    Med. 

Times,  Nov.  1878. 


106  MEDICAL  DIAGNOSIS. 

monoplegia"  on  record  the  ascending  parietal  and  superior  parietal 
convolutions  have  been  found  diseased.  Sensation  is  not  affected ; 
the  arm  is  apt  to  become  gradually  involved  in  the  palsy  ;  in  Ferrier's 
case  ^  the  lesion  was  in  the  quadrilateral  lobule  on  the  internal  aspect 
of  the  hemisphere  and  in  the  upper  extremity  of  the  ascending 
parietal  and  frontal  convolutions. 

There  are  many  other  kinds  of  limited  palsies  of  cerebral  origin, 
such  as  of  the  tongue,  glossoplegia,  of  the  face  and  tongue,  facio- 
lingual  monoj^legia,  of  the  eye  muscles,  oculomotor  monoplegia.!  ^-^d 
half  blindness,  hemianopsia^  to  all  of  which  I  can  only  refer,  since 
our  knowledge  is  not  definite  enough  to  lay  down  concise  conclu- 
sions for  diagnosis.  In  part,  too,  they  will  be  discussed  farther  on. 
It  must,  however,  be  added  that  in  all  these  limited  palsies  trace- 
able to  disease  of  the  brain  we  are  apt  to  have  such  symptoms  as 
are  common  in  brain  affection, — headache,  giddiness,  and  the  like. 
These  aid  us  in  understanding  the  nature  of  the  disorder. 

PARAPLEGIA. 

This  differs  from  hemiplegia  in  the  palsy  occurring  on  both  sides, 
yet  being,  in  the  vast  majority  of  instances,  limited  to  the  lower  or 
the  upper  extremities.  Its  almost  invariable  cause  is  a  lesion  of  the 
spinal  cord.  In  truth,  if  we  call  hemiplegia  paralysis  from  brain  dis- 
ease, we  may  call  paraplegia  paralysis  from  spinal  disease.  Paraple- 
gia is  generally  due  to  a  marked  organic  lesion  ;  but  there  are  cases 
in  wliich  it  exists  independently  of  any  recognizable  structural  change, 
and  in  wliich  it  results  from  poisons,  from  fatigue,  from  excesses. 

The  disorder  generally  comes  on  slowly.  At  first  the  patient  only 
loses  the  steadiness  of  his  gait ;  gradually  he  is  deprived  of  all  power 
of  motion,  but  the  intellect  and  the  nerves  of  special  sense  remain  un- 
affected. If  the  lesion  be  in  the  lumbar  part  of  the  cord,  the  palsy  is 
confined  to  the  lower  extremities  and  to  the  pelvic  muscles ;  if  the 
dorsal  portion  be  attacked,  we  find,  in  addition,  signs  of  paralysis  of 
the  abdominal  walls  and  of  the  sphincters,  tympanites,  and  somewhat 
impeded  breathing.  In  disease  of  the  upper  section  of  the  cord  there 
is  coexisting  palsy  of  the  upper  extremities,  with'  dilated,  sluggish 
pupils,  and  difficulty  in  deglutition  and  in  respiration.  In  the  muscles 
supplied  by  nerves  which  originate  in  healthy  marrow,  involuntary 
contractions  or  reflex  phenomena  can  be  induced, — are,  indeed,  gen- 
erally exaggerated, — and  the  striking  effects  of  strychnine,  when  given 
in  doses  sufficient  to  produce  its  peculiar  muscular  spasms,  are  mani- 

1  Brain,  vol.  iii.,  1880. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  107 

fested.  The  palsied  muscles,  in  the  majority  of  the  affections  occa- 
sioning the  paraplegia,  undergo  wasting,  and  often  do  not  respond  to 
the  electrical  stimulus. 

Paraplegia  is  generally  more  marked  on  one  side  than  on  the  other^ 
and  the  paralysis  of  motion  is  apt  to  be  associated  with  complete  an- 
aesthesia. When,  as  sometimes  happens,  the  mischief  is  limited  to 
a  lateral  segment  of  any  part  of  the  cord,  there  is  paralysis  of  mo- 
tion on  the  same  side  of  the  body,  and  of  sensation  on  the  other. 
Preceding,  or  even  attending,  many  cases  of  paraplegia,  is  a  symptom 
which  belongs  exclusively  to  affections  of  the  cord :  a  spasm  of  the 
flexor  muscles  of  the  lower  limbs,  so  powerful  that  the  anterior  parts 
of  the  thighs  come  almost  in  contact  with  the  abdomen,  while  the 
heels  are  drawn  up  so  as  to  touch  the  back  of  the  thighs.^ 

Let  us  now  take  a  cursory  view  of  the  different  forms  of  spinal 
paraplegia. 

SUDDEN   PARAPLEGIA. 

Spinal  Hemorrhage. — Sometimes  the  paralysis  occurs  suddenly, 
and  in  consequence  of  an  injury  to  the  spine,  of  a  displacement  sub- 
sequent to  a  disease  of  the  bones,  of  blood  extravasated  into  the 
canal,  of  poisons,  as  the  lathyrus  sativus,^  or  of  bulbar  or  spinal  dis- 
order from  sudden  displacement  of  the  cerebro-spinal  fluid  following 
blows  on  the  head.^  When  either,  of  the  first  two  causes  has  led  to 
the  sudden  palsy,  the  diagnosis  is  materially  aided  by  the  history  of 
the  case,  and  by  a  close  examination  of  the  vertebral  column.  But 
if  there  be  no  signs  of  a  disease  of  the  bones  or  of  the  intervertebral 
cartilages,  we  may  suspect  a  spinal  hemorrhage  to  have  produced  the 
sudden  and  complete  paraplegia,  developing  as  it  does  in  a  few  min- 
utes ;  and  this  suspicion  becomes  much  strengthened  if  violent  local- 
ized pain  in  the  back  exist  or  have  preceded  the  rapid  palsy,  if  the 
patient  be  unable  to  retain  his  urine  or  fseces,  and  if  the  affected 
limbs  be  relaxed  and  largely  deprived  of  sensation.  The  seat  of  pain 
corresponds  to  the  seat  of  the  apoplexy.  The  pain  occurs  in  dis- 
tressing paroxysms  and  passes  along  the  course  of  the  nerves  com- 
pressed by  the  extravasation.  Where  the  hemorrhage  is  meningeal, 
there  is  more  persistent  pain,  with  rigidity  of  the  spine,  spasms 
of  the  legs,  slighter  disturbance  of  sensibility,  much  less  quickly  in- 
creasing paralysis,  and  there  is  more  apt  to  be  spasmodic  retention  of 

^  Brown-Sequard's  Lectures  on  the  Nervous  Centres,  p.  114. 
^  Irving,  Indian  Annals,  No.  12,  referred  to  in  Brit,  and  For.  Med.-Chir.  Rev., 
Oct.  1860. 

^  Duret,  Traumatismes  cerebraux,  Paris,  1878. 


108  MEDICAL  DIAGNOSIS. 

urine.  The  absence  of  early  fever  distinguishes  the  spinal  hemor- 
rhage from  spinal  meningitis ;  subsequent  fever  bespeaks  the  occur- 
rence of  this  as  a  complication.  The  muscular  spasm  is  sometimes 
so  severe  that  it  has  been  mistaken  for  tetanus,  which  lacks  the  vio- 
lent pain  in  the  back.  The  most  common  causes  of  spinal  hemor- 
rhage are  blows  and  falls  on  the  back  or  falls  on  the  feet.  It  is  also 
met  with  in  diseases  with  hemorrhagic  tendencies,  in  convulsive 
affections,  and  in  the  course  of  myelitis.  Hemorrhage  into  the  mem- 
branes may  result  from  the  rupture  of  an  aneurism  of  a  vertebral 
artery. 

Paraplegia  sometimes  develops  in  persons  who  emerge  directly 
from  compressed  air  into  the  ordinary  atmosphere,  as,  for  instance, 
divers  and  workers  in  caissons.  There  may  be  besides  numbness 
and  tingling,  nausea  and  vomiting,  headache,  vertigo,  a  sense  of 
throbbing,  palpitation,  oppression  of  the  chest,  bleeding  from  the 
nose,  and  loss  of  consciousness.  The  condition  is  believed  to  be 
due  to  sudden  setting  free  of  gases  dissolved  in  the  blood  as  a  result 
of  the  increased  pressure. 

But  besides  these  causes,  others  lead  rapidly  to  paraplegia.  Soften- 
ing of  the  cord  may  have  progressed  latently  until  the  degeneration 
destroys  the  continuity  of  the  conducting  tubules,  when  palsy  at  once 
takes  place.  Then  there  are  cases  following  violent  exercise  or  sexual 
excesses,  cases  for  which  neither  during  life  nor  after  death  an  organic 
cause  can  be  assigned,^  and  which  are  regarded  as  due  to  enfeeble- 
ment  of  functional  power.  The  disorder  is  much  more  apt  to  come 
on  quickly  than  gTadually,  and  rest  and  a  tonic  treatment  are  likely 
to  be  followed  by  decidedly  good  effects.  But  in  regard  to  all  these 
cases  of  functional  palsy,  the  same  as  m  regard  to  reflex  palsies, 
science  is  more  and  more  narrowing  their  number  by  finding  some 
organic  affection  m  the  cord,  often  secondary  to  an  ascending  neuritis. 
Indeed,  their  very  existence  is  now  for  the  most  part  denied. 

Acute  Ascending  Paralysis. — Yet  another  variety  of  paraple- 
gia which  may  happen  rapidly  is  that  form  which  has  been  described 
as  acute  ascending  paralysis,  or  Landry's  paralysis.  It  may  come  on 
after  fatigue  and  exposure  in  persons  in  perfect  health,  generally  in 
men  between  twenty  and  forty  years  of  age.  Usually  there  is  little  or 
no  fever  except  at  the  onset.  Numbness  and  tmgling,  and  slight  pain 
in  the  loAver  extremities,  .are  soon  followed  by  loss  of  muscular  power, 
which,  in  turn,  goes  on  rapidly,  generally  in  a  few  days,  to  complete 

^  For  instance,  Case  XVIII.  in  Gull's  series  in  Guy's  Hosp.  Rep.,  vol.  iv.,  3d 
Series. 


DISEASES  OF  THE  BRAIN   AND  SPINAL   CORD.  109 

paraplegia.  The  legs  are  relaxed  and  immovable,  the  muscles  of  the 
trunk  are  next  affected,  then  the  upper  extremities  become  implicated, 
and  sensation,  Avhich  at  first  was  normal,  is  somewhat  enfeebled 
though  never  to  a  marked  degree  ;  occasionally  the  arms  are  involved 
before  the  legs.  The  patient  is  restless,  sleepless,  but  his  intelligence 
is,  as  a  rule,  unimpaired,  and  we  find  no  bedsores  and  no  palsy  of  the 
bladder  or  rectum.  The  respiration  and  circulation  in  the  progress 
of  the  disease  become  embarrassed,  inability  to  swallow  occurs, 
there  is  acute  enlargement  of  the  spleen,  and  sudden  death  ensues 
within  a  month  from  the  time  of  the  seizure,^  or,  indeed,  the  case  may 
end  fatally  in  less  than  a  week.  But  all  cases  do  not  run  so  rapid  a 
course ;  and,  m  truth,  we  meet  with  instances  in  which  the  disorder 
is  rather  chronic  than  acute,  or  is  arrested.  The  muscles  do  not 
atrophy,  and  their  electrical  excitability  is  unimpaired,  which  is  a 
very  valuable  diagnostic  test.  About  the  reflexes  the  statements  are 
conflicting.  It  is  most  likely  that  at  first  both  the  superficial  and  the 
deep  reflexes  are  absent,  and  that  they  do  not  return,  certainly  the 
knee-jerk  does  not,  except  when  the  paralysis  passes  away.  Jaccoud^ 
tells  us  that  in  the  cases  he  observed  the  reflex  movements  were 
abolished.  In  Mills's  case^  which  recovered,  both  the  superficial  and 
deep  reflexes  were  completely  lost.  The  disease  occurs  generally  be-- 
tween  the  ages  of  twenty  and  forty,  and  follows  toxsemias  and  infec- 
tions, such  as  influenza,  diphtheria,  typhoid  fever,  and  smallpox. 
Gowers  mentions  a  case  following  pelvic  cellulitis.*  The  malady  is 
looked  upon  as  being  an  affection  of  the  peripheral  nerves,  though 
the  central  nervous  system  is  not  infrequently  involved.  Toxic  in- 
fluences of  invachng  micro-organisms  are  thought  to  give  rise  to  it.^ 

The  disease  which  most  resembles  acute  ascending  paralysis  is 
acute  progressive  or  multiple  neuritis.  But  here  sensation  is  rapidly 
lost,  and  so  is  the  electrical  excitability. 

Multiple  Neuritis. — When  nerve  after  nerve  rapidly  inflames, 
or  the  inflammation  occurs  at  one  time,  an  extensive  palsy  is  c{uickly 
developed.  The  disease  is  an  affection  of  the  peripheral  nerves, 
though  it  has  the  misleading  symptoms  of  a  spinal  malady.  It  attacks 
both  sexes,  is  most  common  between  the  ages  of  thirty  and  flfty,  and, 
though  it  may  follow  altered  blood-states  or  rheumatism,  or  be  due 

^  As  in  the  case  reported  by  Hayem,  Travaux  de  la  Societe  Medicale  d' Obser- 
vation, tome  ii.,  1867  ;  see  also  Leyden's  Klinik  der  Riickenmarkskrankhfeiten. 
^  Clinique  Medicale. 

^  Transactions  of  the  Assoc,  of  Amer.  Phys.,  vol  vii.,  1892. 
*  Diseases  of  the  Nervous  System,  3d  ed.,  1899. 
^  Cramer,  Centralblatt  fiir  Pathologie,  Jan.  1892. 


110  MEDICAL  DIAGNOSIS. 

to  exposure,  by  far  its  most  frequent  cause  is  chronic  alcholism.  It 
has  been  observed  in  the  sequence  of  a  number  of  infectious  diseases, 
toxEemias  and  septicaemias,  and  also  as  a  result  of  the  medicinal 
administration  of  arsenic,  of  lead,  and  of  silver.  It  has  generally  an 
acute  or  a  subacute  beginning,  with  decided  mcrease  in  temperature. 
At  first  vague,  then  more  decided  pains  are  felt  in  the  extremities, 
cMefly  in  the  fingers  and  toes,  and  these  pains  soon  become  darting 
or  burning  and  may  occur  in  paroxysms.  The  pain  is  often  preceded 
by  tinglmg  and  by  cramps,  is  increased  by  motion,  and  is  associated 
with  tenderness  of  the  affected  nen^e-trunks  and  with  both  skin  and 
muscle  tenderness  of  the  parts  to  which  they  are  distributed ;  finally 
this  increased  sensibility  may  give  way  to  antesthesia. 

The  palsy  shows  itself  often  first  in  the  arms,  the  earliest  loss  of 
power  being  e^adent  in  the  extensors  of  both  sides.  Soon  the 
muscular  weakness  is  seen  also  in  the  legs,  'and  the  trunk  muscles 
and  face  riiuscles  may  become  involved.  But  the  first  signs  of  palsy 
may  be  in  the  legs,  and  manifest  itself  in  a  peculiar  gait.  The  sym- 
metrical character  of  the  palsy  is  always  noticeable,  as  are  also  the 
, double  wrist-drop  and  foot-drop.  The  parts  afi'ected  waste,  and  lose 
their  reflex  excitability  :  the  loss  of  the  knee-jerk  is  especially  pro- 
nounced. The  muscles  do  not  react  to  faradization,  though  they  may 
to  galvanism  ;  often,  indeed,  they  present  the  reaction  of  degeneration.: 
the  nerves  are  unmfluenced  by  the  electric  stmiulus.  (Edema  of  the 
arms  and  legs  is  frequent,  and  profuse  sweating  is  not  uncommon. 
Sometimes  muscular  incoordination  is  the  most  promment  symptom. 

The  disease  may  run  on  to  complete  palsy  of  the  limbs  m  less 
than  two  weeks,  and  death  result  from  paralysis  of  the  respiratory 
muscles  ;  or  the  affection  may  pass  mto  a  chronic  conchtion,  and  a 
slow  improvement,  with  return  of  power  in  the  muscles,  take  place. 
In  protracted  cases  contraction  of  unopposed  muscles  occasions  de- 
formities, and  there  are  arthritic  adhesions,  glossy  skin,  and  thicken- 
mg  of  the  skin. 

The  diagnosis  is  generally  easy.  The  tingling  in  the  extremities, 
the  cutaneous  and  muscular  sensitiveness,  the  distribution  of  the  symp- 
toms, the  early  development  of  muscular  weakness,  and  the  palsy  of 
the  extensors  distmguish  the  disease  from  rheumatism.  In  some  in- 
stances, where  it  is  difficult  to  elicit  tenderness  of  nerve-trunks,  or 
where  this  symptom  is  wanting,  where  the  muscular  tenderness  is 
not  marked,  where,  moreover,  the  palsy  is  slight  and  incoordination 
of  movement  is  observed,  the  smiilarity  to  locomotor  ataxia,  is  great, 
and  the  eye-symptoms  of  this  affection  alone,  if  present,  will  help  to 
a   correct  conclusion.      Further,  girdle-sense  and  lightning-pains  are 


DISEASES  OF  THE  BRAIN   AND   SPINAL   CORD. 


Ill 


absent  in  peripheral  neuritis,  while  wasting  is  not  generally  observed 
in  posterior  sclerosis.  In  ordinary  cases  the  greatest  resemblance  is 
to  those  instances  of  acute  myelitis  which  run  a  rapid  course,  and  espe- 
cially those  in  which  muscular  wasting  is  marked.  To  acute  ascending 
paralysis  intense  cases  of  the  disease  also  bear  a  strong  likeness. 

In   the   following  table   are    contrasted  the   features   of  multiple 
neuritis,  of  acute  myelitis,  and  of  acute  ascending  paralysis. 


Multiple  Neuritis. 

Fever,  with  at  first  de- 
cided elevation  of  tem- 
perature. 

Palsy  begins  in  forearms, 
extends  to  legs  and 
trunk,  or  may  shovsr 
itself  first  in  the  legs  ; 
double  wrist-drop  and 
foot-drop  ;  palsies  sym- 
metrical. 

Muscles  atrophy  rapidly. 
Trophic  changes  in  skin 
and  nails  common ;  no 
bedsores. 

Marked  pain  and  sensory 
disturbances,  hyperaes- 
thesia  especially,  later 
anaesthesia  in  the  area 
of  distribution  of  the 
inflamed  nerves  ;  mus- 
cular tenderness  ;  ten- 
derness of  nerve-trunks. 

Loss  of  electrical  excita- 
bility. Generally  reac- 
tion of  degeneration. 

Reflex  action  lost,  espe- 
cially deep  reflexes  and 
muscle  reflex. 

Sphincters  unaffected. 

No  bulbar  symptoms, 
though  respiratory 
palsy  may  happen. 

Mind  unaffected,  except 
in  the  alcoholic  and  tox- 
Eemic  cases. 


Acute  Myelitis. 
Fever  generally  moderate. 


Palsy  generally  affects 
only  legs  and  lower  part 
of  trunk,  though  it  may 
affect  arms. 


Muscles  atrophy  rapidly. 
Trophic  changes 
marked  ;  bedsores. 


Acute  Ascending 
Paralysis. 
No,  or  only  slight,   eleva- 
tion of  temperature. 

Paralysis  rapidly  extend- 
ing from  lower  extrem- 
ities ;  relaxed  muscles. 


No  muscular  atrophy.  No . 
trophic  changes ;  no 
bedsores. 


No  pain  or  tenderness  of     No  marked  pain  or  more 


nerve-trunks  ;  complete 
anaesthesia  below  le- 
sion ;  zones  of  hyperses- 
thesia  corresponding  to 
lesion. 


Loss  of  electrical  excita- 
bility. Generally  reac- 
tion of  degeneration. 

Excessive  reflex  action, 
except  in  parts  deriving 
nerve-supply   from    in- 

.  jured  centres,  there  lost. 

Sphincters  affected  early. 

Bulbar  symptoms  rare  ; 
failure  of  respiratory 
power  may  happen. 

Mind  unaffected. 


than  dulling  of  sensa- 
tion in  affected  parts  ; 
no  tenderness  of  nerve- 
trunks. 


No    change     in    electrical 
excitability. 

Absence    of    reflexes    the 
rule. 


Sphincters  nearly  *lways. 
escape. 

Bulbar  symptoms  fre- 
quent. 

Mind  remains  clear. 


112  MEDICAL  DIAGNOSIS. 

The  various  causes  of  multiple  neuritis  give  rise  to  some  differ- 
ences in  the  symptoms,  by  the  close  study  of  which  we  may  infer  the 
cause.  Thus,  in  neuritis  from  metallic  poisons  the  disorder  is  con- 
fined to  the  arms,  as  in  lead  poisoning,  or  is  found  in  the  arms  first 
and  subsequently  attacks  the  legs,  as  in  the  neuritis  of  arsenical 
poisoning.  In  malarial  neuritis  the  legs  are  first  attacked,  and  the 
neural  malady  may  be  confined  to  them.  The  neuritis  due  to  diph- 
theria often  gives  rise  to  paralysis  of  the  palate,  of  the  fauces,  of  ac- 
commodation, and  of  the  lower  extremities,  at  times  closely  simu- 
lating locomotor  ataxia.  Neuralgic  pain  of  irregular  distribution,  with 
sugar  in  the  urine,  is  characteristic  of  the  neuritis  of  diabetes.  In 
alcoholic  neuritis  all  the  limbs  are  affected,  the  pains  are  very  severe, 
and  both  sides  of  the  face  may  become  mvolved.  Symptoms  much 
the  same  with  reference  to  the  distribution  of  the  motor  and  sensory 
disturbance  happen  in  the  multiple  neuritis  from  cold.  In  the  toxic 
cases  the  face  is  also  apt  to  be  involved,  and  the  optic  nerves  seem  to 
be  only  m  them  affected.  The  symptoms  due  to  the  neuritis  of  leprosy 
resemble  greatly  those  of  syringo-myelia.  In  pysemic  and  septicsemic 
cases  there  are  the  history  and  the  pyrexia  to  guide  us.  In  the  multi- 
ple neuritis  of  influenza  comparatively  little  pain  occurs  ;  but  con- 
siderable palsy,  some  facial  paralysis,  and  difficulty  of  swallowing  are 
not  uncommon.  Multiple  neuritis  may  occur  in  the  old  without 
obvious  cause.  In  some  cases  it  manifests  a  peculiar  tendency  to 
recurrence. ' 

Infectious  Paralyses. — These  are  specially  seen  in  children,  and 
are  mostly  of  the  spinal  or  peripheral  type,  though  they  may  be  cere- 
bral, or  occur  in  varied  combmation.  We  may  find  them  affecting 
the  two  arms  or  the  two  legs,  or  all  four  limbs.  Many  of  the  cases 
are  clearly  instances  of  multiple  neuritis,  others  of  neuritis  associated 
with  myelitis  ;  the  palsy  is  frequently  very  wide-spread.  These  infec- 
tious paralyses  are  noticed  after  influenza,  typhoid  fever,  measles, 
scarlet  fever,  diphtheria,  mumps,  whooping-cough.  They  present 
clinically  the  traits  of  the  pathological  lesions  occasioning  them,  and 
in  their  diagnosis  the  history  of  the  preceding  attack  is  of  the  utmost 

importance. 

GRADUAL   PARAPLEGIA. 

This  occurs  in  congestion,  in  acute  and  chronic  inflammation  of 
the  meninges,  in  myelitis,  in  softening,  in  atrophy,  in  sclerosis,  in 
compression  of  the  cord,  and  from  reflex  irritation.  These  are  some 
of  the  marks  of  discrimination : 

Spinal  Congestion. — There  are  no  certam  symptoms  of  spinal 
congestion.     It  is  likely  that  the  aching  in  the  spine  and  legs  that 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  113 

comes  on  in  weakly  persons  who  have  remained  for  a  length  of  time 
on  their  backs  is  due  to  passive  spinal  congestion.  More  active  spinal 
congestion  may  occur  in  diseases  of  the  heart  and  in  gouty  persons, 
and  is  perhaps  the  cause  of  the  nocturnal  muscular  jerkings  from 
which  they  suffer. 

Spinal  Anaeniia. — Except  as  part  of  a  general  anaemic  state,  or 
after  severe  hemorrhages,  there  is  no  proof  that  spinal  anaemia  exists. 
The  symptoms  of  hysterical  or  "  irritable  spine,"  or  "  spinal  irritation," 
a  disease  met  with  in  hysterical  and  anaemic  young  women,  are  sup- 
posed to  be  due  to  it.  These,  besides  palpitation,  neuralgic  pains 
in  the  chest  and  abdomen,  and  aching  in  the  inactive  and  sensitive 
limbs,  are  pain  along  the  spine,  and  marked  tenderness  on  pressure 
on  the  spinous  processes  of  the  vertebrae.  But  that  spinal  anaemia  is 
the  determining  cause  is  very  doubtful.  In  anaemia  of  the  cord  fol- 
lowing hemorrhage,  which  has  generally  happened  from  an  abdomi- 
nal organ,  the  weakness  of  the  legs  and  arms  may  pass  into  complete 
motor  paraplegia.  In  some  instances  Leyden  has  observed  attending 
hyperaesthesia. 

Spinal  Meningitis. — In  inflammation  of  the  meninges  we  en- 
counter severe  pain  in  the  back,  little  influenced  by  pressure  upon 
the  spine,  yet  ag-gravated  by  movement,  even  by  the  acts  of  defecation 
and  urination ;  sometimes  a  sensation  as  if  a  cord  had  been  drawn 
around  the  belly  ;  pains  in  the  limbs  similar  to  those  of  rheuma- 
tism ;  cutaneous  hyperaesthesia  or  anaesthesia ;  muscular  twitchings, 
rigidity,  and  contractions,  more  or  less  permanent  and  pamful ;  in- 
creased superficial  and  deep  reflexes,  when  the  disease  is  above  the 
lumbar  enlargement  of  the  cord ;  very  commonly  distressmg  spasms 
in  the  muscles  of  the  back,  and  spasms  in  the  limbs  occasioned  by 
attempts  to  move  them ;  rigidity  of  the  spinal  column ;  bedsores ; 
dyspnoea ;  retention  of  urine  ;  vasomotor  derangement ;  yet  only  in- 
complete paralysis,  or,  indeed,  none  at  all.  In  the  acute  form  we 
have  decided  fever.  When  marked  paraplegia  follows  the  symptoms 
mentioned,  we  may  suspect  the  development  of  myelitis,  or  that  an 
effusion  has  taken  place  which  compresses  the  spinal  cord.  Cases  of 
spinal  meningitis  occur  from  falls  and  shocks,  from  exposure  to  cold, 
as  a  consequence  of  adjacent  disease,  and  in  the  course  of  general 
infectious  processes.  They  are  not  unusual  among  soldiers  who  have 
slept  on  damp  ground. 

As  regards  the  special  membranes  involved,  there  is  no  certainty 
in  diagnosis.  The  symptoms,  save  in  the  acute  purulent  forms  of  the 
disease,  are  slow  in  developing.  In  inflammation  of  the  dura  mater, 
pachymeningitis,  the  radiating  pains  are  very  severe,  but  there  is  less 


114  MEDICAL  DIAGNOSIS. 

vertebral  pain  and  stiffness  in  the  back :  these  signs  are  seen  in  their 
fullest  expression  in  inflammation  of  the  pia  mater  and  arachnoid. 
In  inflammation  of  the  inner  surface  of  the  dura  mater,  j^achymenin- 
gitis  spinalis  interna,  which  particularly  happens  in  the  cervical  region, 
the  symptoms  are  chiefly  referred  thither ;  and  stiffness  of  the  neck," 
paralysis  in  the  upper  extremities,  especially  in  the  parts  supplied  by 
the  median  and  ulnar  nerves,  claw-like  hands,  contractions,  severe 
pains  m  the  arms,  spots  of  anaesthesia,  and  herpetic  eruptions  are 
common.  At  a  later  period,  as  the  hypertrophic  thickenmg  of  the 
dura  extends  and  the  cord  is  more  and  more  compressed,  the  para- 
lyzed muscles  may  undergo  wasting.  There  is  a  hemorrhagic  form  of 
pachymeningitis  interna  having  the  same  causes  as  hsematoma  of  the 
dura  mater  of  the  brain,  and  often  accompanying  it. 

Myelitis. — Myelitis  presents  many  of  the  same  symptoms  as 
spinal  meningitis,  with  which,  in  fact,  it  may  be  associated.  Fre- 
quently the  symptoms  come  on  by  slow  degrees,  and  the  paraplegia, 
a  very  distinctive  symptom,  gradually  becomes  complete.  There  is 
strong  knee-jerk  with  ankle  clonus.  Contractions  of  the  muscles  are 
uncommon,  and  not  permanent,  unless  late  in  the  disease ;  the 
muscles  are  usually  flaccid ;  there  is  comparatively  little  pain,  none 
on  pressure  at  any  part  of  the  spine,  or  on  motion,  and  anaesthesia 
sooner  or  later  shows  itself.  Further,  we  generally,  though  not  con- 
stantly, find  the  urine  alkaline,  and,  as  a  rule,  retention  of  urine  and 
a  want  of  control  over  the  rectum  exist,  bedsores  form  readily,  and 
the  temperature  of  the  palsied  is  lower  than  that  of  the  healthy  parts. 

In  acute  cases  there  are,  as  in  acute  spinal  meningitis,  raised  tem- 
perature and  a  frequent  pulse.  The  fever  is  moderate  and  irregular. 
There  is  pain  in  the  back,  not  increased  by  movements,  and  pain  in 
the  limbs  preceded  by  numbness  or  burning.  In  many  instances  we 
notice  erection  of  the  penis.  Spasm  in  the  extensor  muscles  is 
always  of  significance.  Reflex  movements  in  the  relaxed  palsied 
limbs  are  gradually  abolished  as  the  process  of  inflammation  and 
softening  affects  the  gray  matter  of  the  cord.  In  dorsal  myelitis  the 
trunk  reflexes  are  impaired,  but  the  reflex  excitability  remains  ex- 
cessive in  the  parts  supplied  by  nerves  arising  below  the  level  of  the 
greatly  diseased  centres.  In  disease  of  the  lumbar  enlargement  the 
knee-jerks  are  wholly  lost. 

An  altered  sensilDility  to  heat  and  cold,  when,  for  instance,  a  sponge 
soaked  in  warm  water  or  a  piece  of  ice  is  applied  to  the  spine  over  the 
inflamed  spot,  has  been  spoken  of  as  a  diagnostic  test ;  in  either  case 
the  sensation,  when  the  diseased  part  is  reached,  changes  to  a  burning 
sensation.     This  symptom  is,  however,  far  from  constant,  and  cannot 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  115 

be  accepted  as  conclusive.  There  is  a  zone  of  liyperaesthesia  at  the 
level  of  the  lesion,  and  corresponding  to  this  a  zone  of  constriction 
or  "  girdle  pain."  Below  the  level  of  the  lesion  the  loss  of  sensation 
is  complete.  The  paraplegia,  even  in  acute  cases,  is  not  suddenly- 
developed.  Yet  we  meet  with  exceptions.  There  are  instances  in 
which  it  comes  on  almost  as  rapidly  as  in  spinal  hemorrhage.  These 
are  mostly  instances  of  hemorrhagic  myelitis ;  yet  even  these  are 
generally  preceded  by  tingling  in  the  limbs  and  other  sensory  disturb- 
ance, and  there  is  fever,  but  not  the  acute  spinal  pain  of  hemorrhage. 
A  paralysis  of  the  bladder  may  be  the  first  symptom  of  myelitis,  and 
paralysis  of  motion  and  of  sensation  quickly  follow.^ 

Myelitis  may  be  the  result  of  cold  and  exposure,  of  over-exertion, 
of  syphilis,  of  peripheral  irritation,  of  pressure,  as  from  disease  of  the 
vertebrae,  of  tumors,  connected  with  the  bones  or  membranes,  of 
parasites,  of  aneurisms,  encroaching  on  the  cord  and  setting  up  dis- 
ease there,  of  injuries  to  the  cord,  or  of  concussion  of  the  spine  after 
railway  accidents.  It  is  sometimes  met  with  in  the  course  of  measles 
and  of  smallpox,  and  of  typhoid  and  typhus  fevers  and  toxic  blood- 
states,  such  as  gout  and  syphilis.  Compression  as  a  cause  has  been 
noted  in  the  cervical  as  well  as  in  the  other  portions  of  the  spine. 
Paralysis  of  the  arms,  with  dilated  or  contracted  pupil  and  very  slow 
pulse,  is  among  the  chief  symptoms  of  the  "  cervical  paraplegia." 
Pain  in  the  limbs,  hypersesthesia,  muscular  contraction,  spasms,  and 
great  reflex  irritability  are  among  the  earlier  symptoms  of  this  as  of 
all  the  other  forms  of  myelitis  from  pressure ;  but  as  the  case  pro- 
gresses the  reflex  irritability  is  lost.  Yet  recovery,  almost  complete, 
is  possible.^  • 

Unilateral  flushing  and  sweating  have  been  observed  and  a  retro- 
pharyngeal abscess  may  form.  When  the  dorsal  region  is  involved 
obvious  deformity  may  be  present.  The  paralysis  of  the  lower  ex- 
tremities develops  late  and  progresses  slowly.  Radiating  pains  are 
present,  and  the  knee-jerks,  occasionally  absent  at  first,  finally  become 
exaggerated.  Compression  of  the  lumbar  cord  is  attended  with  loss 
of  control  of  the  sphincters,  while  the  knee-jerks  are  lost. 

In  looking  at  the  symptoms  which  mark  the  extent  and  exact 
site'  of  the  inflammation,  we  find  in  the  common  form,  where  the 
disease  affects  a  considerable  portion  of  the  thickness  of  the  cord, 
— transverse  myelitis, — with  the  ordinary  symptoms  of  complete  para- 
plegia and  anaesthesia,  that  the  reflex  excitability  is  lost  in  the  parts 

'  Erl),  in  Ziemssen's  Cyclopaedia,  vol.  xiii. 
2  Buzzard,  Brain,  April,  1880. 


116  MEDICAL  DIAGNOSIS. 

supplied  by  the  nerves  coming  from  the  affected  portion  of  the  cord, 
and  is  preserved  or  increased  in  the  parts  supplied  by  nerves  arising 
from  the  cord  below  the  diseased  area,^  and  the  muscles  respond 
to  the  electric  current.  This  is  not  the  case  in  central  myelitis^  which, 
moreover,  usually  runs  a  rapid  course,  in  which  there  is  speedy  loss 
of  sensation  and  of  reflex  action,  and  in  which  muscular  atrophy  soon 
shows  itself.  In  disseminated  myelitis^  a  form  where  several  foci  of  in- 
flammation are  present,  there  are  lulls  and  exacerbations,  the  paral- 
ysis is  not  so  constant  nor  so  complete,  although  it  may  be  m  all 
four  limbs,  spastic  symptoms  are  not  uncommon,  and  the  disease 
develops  itself  after  acute  maladies,  as  after  smallpox.  Hemorrhagie 
myelitis  is  usually  central ;  the  paraplegia  comes  on  in  less  than  an 
hour.  In  children  the  anterior  cornua  are  apt  to  be  affected,  and 
the  disease  is  known  as  poliomyelitis. 

Spinal  Scleroses. — Sclerosis  of  the  spinal  cord  may  be  primary 
or  secondary.  The  latter  is  represented  by  the  descending  or  ascend- 
ing degenerations  that  follow  lesions  of  brain,  cord,  or  posterior  nerve- 
roots.  In  the  former  are  included  the  so-called  system  diseases, — 
posterior  sclerosis,  locomotor  ataxia,  and  lateral  sclerosis.  The  scle- 
rosis where  brain  and  cord  both  suffer,  we  shall  discuss  with  the 
forms  of  tremor ;  posterior  sclerosis  of  the  cord  produces  the  symp- 
toms of  locomotor  ataxia,  not  of  palsy. 

Lateral  Sclerosis. — Primary  sclerosis  of  the  lateral  columns  in 
which  the  anterior  horns  are  not  affected  shows  the  group  of  symp- 
toms described  as  spasmodic  dorsal  tabes  by  Charcot,  or  spastic  spinal 
paralysis  by  Erb.  It  is  characterized  by  a  sensation  of  weakness  in 
the  back,  a  gradually  increasmg  loss  of  muscular  power  in  the  lower 
extremities,  proceeding  slowly  from  below  upward,  and  associated 
with  reflex  spasms  and  persistent  muscular  contractions,  with  in- 
creased tendon  reflex,  but  without  impairment  of  sensibility,  or 
trophic  disturbances,  or  bedsores,  or  vesical  disorder.  The  muscles 
are  well  nourished,  or  only  very  slightly  wasted ;  the  gait  is  peculiar, 
the  walk  being  on  the  toes,  and  as  the  foot  touches  the  ground 
a  trembling  happens.  Sometimes  there  is  marked  contraction  of 
the  adductors  of  the  thighs,  and  the  knees  are  in  contact  or  even 
crossed.  The  function  of  the  sphincters  may  be  enfeebled  or  lost. 
No  cerebral  symptoms  whatever  exist ;  the  electrical  excitability  is 
either  normal  or  somewhat  lessened.  In  rare  instances  the  disease 
begins  in  the  upper  extremities ;    it  is  almost  always  of  very  slow 

^  According  to  Bastian,  total  transverse  lesion  high  up  in  the  cord  abolishes 
the  knee-jerk. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  117 

development.  Occasionally  it  terminates  in  recovery.  It  is  most 
likely  that  the  disease  consists  essentially  in  a  primary  sclerosis  of  the 
pyramidal  tracts,  or  of  the  terminations  of  their  fibres  in  the  motor 
cells  of  the  gray  matter.  But  whether  the  group  of  symptoms  may 
not  be  produced  by  various  lesions  of  the  cord  is  not  settled.  To  an 
infantile  form  of  degeneration  of  the  lateral  columns  McLane  Hamil- 
ton has  called  attention.  Loss  of  power  in  the  lower  extremities, 
muscular  contractions  without  marked  atrophy  or  greatly  impaired 
electro-muscular  contractility,  such  as  happen  in  infantile  paralysis, 
increased  skin  and  tendon  reflexes,  and  absence  of  sensory  disturb- 
ances or  brain-symptoms,  are  the  chief  signs  of  the  affection.^ 

When  sclerosis  affects  the  lateral  columns,  and  is  combined  with 
degeneration  of  the  great  ganglion  cells  in  the  anterior  horns  of  gray 
matter  of  the  cord,  the  portion  which  has  a  controlling  influence  over 
nutrition,  marked  nutritive  changes  happen  in  the  palsied  part,  such 
as  we  find  in  progressive  muscular  atrophy.  But  this  amyotrophie 
lateral  sclerosis^  as  Charcot  has  termed  it,  is  from  the  onset  an  atrophy 
of  a  whole  muscular  group.  It  is  a  disease  closely  allied  to  progressive 
muscular  atrophy,  and,  beginning  in  the  arms,  affects  as  a  rule,  the 
four  limbs  successively,  produces  strange  deformities  in  the  wasted  and 
palsied  limbs,  that  are  agitated  by  fibrillar  movements,  extends  to  the 
hypoglossal  and  the  pneumogastric  nerves,  and  thus  determines  death. 

Tumors  of  the  Cord. — Tumors  of  the  spinal  cord,  either  grow- 
ing from  it  or  its  membranes,  or  originating  in  the  vertebree  and  com- 
pressing the  nerve-structure,  occasion  paraplegia.  The  symptoms 
vary  with  the  situation  and  extent  of  the  growth.  They  depend  first 
upon  the  irritation,  and  later  upon  the  compression,  caused  by  the 
new  formation.  We  suspect  the  affection  if  we  have  signs  of  a  grave 
constitutional  malady  attending  the  slowly  progressing  palsy,  if  this 
be  more  decided  on  one  side  than  on  the  other,  and  if  anaesthesia  be 
found  on  the  side  opposite  to  that  in  which  the  palsy  is  marked.  The 
severe  pain  over  the  locality  of  the  disease,  at  first  neuralgic,  then 
becoming  constant,  is  aggravated  in  paroxysms.  The  pain  is  gener- 
ally felt  on  one  side  first,  and  is  associated  with  tenderness  and 
rigidity  of  the  spine,  and  muscular  spasm  or  rigidity  in  the  limbs. 
Yet,  unless  we  have  distinct  evidence  of  tumors  elsewhere,  the  diag- 
nosis is  never  more  than  an  uncertain  one.  If  multiple  tumors  exist, 
it  may  be  made  positive.  Strong  proofs  of  syphilitic  infection  point 
to  the  spinal  symptoms  being  due  to  a  syphilitic  growth  ;  and  signs 
of  scrofula  or  tubercle  in  the  lungs  or  in  other  internal  organs,  make 

^  Transactions  of  the  American  Medical  Association,  1879. 

8 


113  MEDICAL  DIAGNOSIS. 

it  likely  that  similar  morbid  products  are  the  cause  of  the  palsy. 
Should  a  gradually  progressing  paralysis  suddenly  show  symptoms  of 
acute  myelitis  in  a  person  with  the  constitutional  cachexia  just  men- 
tioned, we  have  an  additional  reason  for  supposing  the  affection  to  be 
tubercular  and  to  be  rapidly  extending.^  Lymphadenomas  elsewhere 
make  it  extremely  probable  that  the  spinal  symptoms  are  owing  to  one 
or  several  of  them  in  the  cord.  Yet  the  spinal  symptoms  in  the  affec- 
tion may  be  really  due  to  myelitis.  In  all  cases  of  suspected  tumor 
we  must  be  careful  to  ascertain  that  bone-disease  is  not  the  cause  of 
the  symptoms.  The  absence  of  sharp  pain  and  the  uniformity  of  the 
palsy  on  both  sides  are  points  of  distinction  as  against  tumors.  The 
early  signs  of  tumor  of  the  cord  suggest  hysteria. 

Reflex  Paraplegia. — Functional  disturbance  of  the  cord  from 
irritation  causing  an  inhibition  of  spinal  centres  is  supposed  to  give 
rise  to  the  so-called  reflex  palsies.  Worms  in  the  intestines  may 
occasion  them.  But  the  most  marked  of  them  is  the  paraplegia  con- 
sequent upon  disease  of  the  bladder.  Yet  it  is  very  doubtful  whether 
there  is  not  always  in  these  reflex  paralyses  organic  disease,  especially 
an  ascending  neuritis,  and  it  is  unlikely  that  reflex  palsies  have  any 
real  existence. 

So  much  for  paraplegia.  We  shall  now  examine  some  of  the  other 
clinical  varieties  of  paralysis  ;  beginning  with  a  group  in  wliich  the 
palsy  is  limited,  though  it  may  be  general. 

PALSIES   USUALLY   LIMITED,    THOUGH   THEY   MAY   BE   GENERAL. 

Hysterical  Paralysis. — We  distinguish  this  form  of  paralysis 
from  that  of  organic  disease  by  its  occurrence  in  hysterical  persons  ; 
its  sudden  appearance,  and  frequently  its  just  as  sudden  disappear- 
ance ;  its  coming  on  generally  under  the  influence  of  some  powerful 
emotion,  often  after  an  attack  of  hysterical  convulsions  ;  the  absence 
of  any  signs  of  a  serious  lesion  of  the  nervous  centres,  except  the 
paralysis ;  the  varying  nature  of  the  palsy,  sometimes  hemiplegia, 
sometimes  paraplegia ;  its  incomplete  character,  the  patient  being  not 
infrequently  able  to  move  while  under  strong  excitement;  and  the 
ease  with  which  reflex  movements  are  brought  on  in  the  seemingly 
helpless  limb.  Then  there  are  nervous  shiverings,  noises  in  the  ears, 
tingling  sensation  in  the  linibs,  and  vasomotor  disturbances  showing 
themselves  by  slight  swelling  of  the  joints  and  elsewhere.  The  mus- 
cles, except  in  cases  of  long  standing,  contract  perfectly  under  both 
the  faradic  and  the  galvanic  current.     The  electro-muscular  sensi- 


'See  cases  of  Hayem,  Archives  de  Physiologie,  1873  ;  and  Erb,  in  Ziemssen's 
Cyclopaedia. 


DISEASES   OF  THE  BRAIN  AND  SPINAL   CORD.  119 

bility  is  either  diminished  or  abohshed.  In  some  cases  galvanic  sen- 
sibiHty  is  lost/  We  never  find  the  reaction  of  degeneration.  Hyper- 
aesthesia,  but  much  more  generally  anaesthesia,  sometimes  only  on 
one  side,  is  observed,  and  this  also  may  involve  the  special  senses  and 
affect  the  muscles.  But  muscular  ansesthesia  may  be  absent  in  hysteria. 
Rapid  changes  occur  in  the  sensibility  under  strong  electric  currents, 
and  there  may  be  a  transfer  of  the  loss  of  sensation  from  the  disordered 
side  to  the  healthy  side,  caused  by  stimulating  the  side  of  the  hemi- 
angesthesia, — by  mustard  or  by  the  faradic  brush,  or  by  certain  metals, 
such  as  gold,  or  by  wood, — or,  indeed,  by  strong  mental  impressions. 

The  eye-symptoms,  as  Charcot  has  pointed  out,^  are  peculiar. 
There  may  be  an  amaurosis,  but  there  is  no  alteration  of  the  papilla ; 
the  constricted  field  of  vision  is  concentric,  not,  as  in  locomotor 
ataxia,  star-shaped,  and  red  is  the  color  that  is  seen  longest.  Then  in 
hysteria  the  eyebrow  on  the  affected  side  is  lower  than  on  the  other 
side,  while  in  true  paralysis  it  is  more  raised  on  the  side  affected. 
Nystagmus  is  never  observed  in  hysteria ;  but  hemianopsia  may  be 
met  with  in  grave  instances. 

Persons  affected  with  hysterical  palsy  are  striking  types  of  a 
nervous  constitution,  and,  as  Sir  James  Paget  ^  mentions,  show  a 
singular  readiness  to  be  painfully  fatigued  by  slight  exertion.  The 
palsy  may  seize  only  upon  one  limb,  or  upon  part  of  one  limb,  or 
upon  special  muscles,  as  those  of  the  pharynx  and  oesophagus,  the 
larynx,  the  intestines,  and  the  diaphragm ;  or  it  may,  although  it 
more  rarely  does,  assume  a  hemiplegic  or  a  paraplegic  form.  Hys- 
terical hemiplegia  presents  a  peculiarity  in  the  gait,  on  which  Todd* 
lays  great  stress.  "  In  walking,  when  the  palsy  is  pretty  complete, 
the  leg  is  drawn  along  as  if  lifeless,  sweeping  the  ground."  It  is  not 
swung  round,  describing  the  arc  of  a  circle,  as  it  is  in  ordinary  hemi- 
plegia. The  palsy  is  almost  invariably  left-sided.  It  is  apt  to  be  con- 
joined to  left-sided  ovarian  tenderness,  and  to  very  decided  anaesthe- 
sia, which  passes  beyond  the  paralyzed  part  to  the  nearest  portion 
of  skin  and  mucous  membrane,  though,  as  a  rule,  still  limited  to  the 
same  side.  Thus  we  find  the  pituitary  membrane  of  one  nostril 
rendered  insensible,  if  the  loss  of  feeling  affect  the  face. 

In  hysterical  paraplegia  we  find  the  same  incompleteness  of  the 

^  Wood,  Nervous  Diseases  and  their  Diagnosis,  887. 

^  International  Clinics,  vol.  i.,  2d  Ser. ,  1892. 

^  Nervous  Mimicry  of  Organic  Diseases,  in  Clinical  Lectures  and  Essays,  Lon- 
don, 1875. 

*  Clinical  Lectures  on  Paralysis  and  other  Affections  of  the  Nervous  System, 
Lecture  XIIL 


120  MEDICAL  DIAGNOSIS. 

palsy  and  the  same  response  to  electric  tests  already  mentioned,  and 
we  are  also  very  apt  to  have  the  symptoms  of  spinal  irritation.  Hys- 
terical contractions  of  the  muscles  especially  affect,  the  lower  extrem- 
ities, though  they  are  not  uncommon  in  the  arm.  These  hysterical 
contractures  generally  come  on  quickly,  appear  to  be  permanent,  and 
to  be  associated  with  loss  of  power,  but  disappear  as  suddenly  as  they 
showed  themselves.  Yet  they  may  really  beconie  permanent  and 
combined  with  sclerosis  of  the  cord,  and  we  may  find  them  associ- 
ated with  tremor,  and  with  exaggerated  knee-jerk.  Ankle  clonus 
has  also  been  observed  by  Charcot  as  occurring  in  hysterical  paral- 
ysis. Gowers,  however,  thinks  that  true  persisting  ankle  clonus  be- 
speaks secondary  organic  disease  in  the  motor  parts  of  the  cord,  while 
a  spurious,  irregular  clonus,  now  ceasing,  now  renewed  by  a  fresh 
contraction  of  the  muscle,  is  characteristic  of  hysteria. 

Very  similar  to  hysterical  paraplegia  is  the  paraplegia  produced  hy 
hypnotic  suggestion.  Charcot  and  Longues  ^  have  called  attention  to 
the  fact  that  in  this  as  well  as  in  the  functional  paraplegia  met  with 
after  railroad  and  other  accidents,  the  so-called  traumatic  hysteria., 
there  is  an  anaesthesia  in  the  palsied  legs  which  follows  the  fold  of 
the  groin  and  excludes  the  genital  organs.  The  same  line  also  en- 
ables us  to  distinguish  between  hysterical  paraplegias  and  those  of 
organic  origin. 

One  of  the  most  difficult  points  with  reference  to  hysteria  is  to 
distinguish  the  hysterical  symptoms  that  arise  in  sclerosis  and  in  my- 
elitis, or  that  follow  injuries  to  the  nervous  system,  from  the  manifes- 
tations of  pure  hysteria.  Nothing  but  a  careful  study  of  the  individual 
case,  of  the  history,  of  the  reflexes,  of  the  electric  reactions,  of  the  line 
of  the  anaesthesia,  of  the  state  of  the  muscles  themselves,  laying  stress 
on  the  absence  of  muscular  wasting,  also  of  girdle  pains,  and  of  incon- 
tinence of  urine  and  of  faeces  in  pure  hysteria,  will  save  from  error. 

Rheumatic  Paralysis. — Rheumatic  paralysis  resembles  hysteri- 
cal paralysis  in  being  ordinarily  limited.  It  may  affect  any  muscle  or 
any  group  of  muscles  in  the  body ;  sometimes  the  rheumatic  poison 
disorders  the  portio  dura,  and  we  observe,  in  consequence,  facial 
palsy ;  or  it  may  fasten  on  the  radial  nerve,  and  we  have  groups  of 
muscles  in  the  forearm  palsied.  Rheumatic  paralysis  is  recognized 
by  the  history  of  the  case ;  by  the  evidences  of  a  rheumatic  attack ; 
by  the  rapid  development  of  the  palsy ;  by  the  pain  which  usually 
attends  it ;  and  by  its  being  unaccompanied  by  symptoms  strictly 
referable  to  a  disease  of  the  nerve-centres.     It  may  or  may  not  be 

^  Charcot,  (Euvres  Completes,  t.  iii.  p.  448. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  121 

attended  by  anaesthesia.  The  muscles  themselves,  certainly  in  those 
cases  m  which  they,  rather  than  a  large  nervous  branch,  are  primarily 
and  chiefly  affected,  are  readily  acted  upon  by  electricity,  unless  their 
structure  be  altered ;  and  the  electro-muscular  sensibility,  though  it 
may  be  lessened,  is  not  abolished. 

Lead  Palsy. — Paralysis  from  lead  poisonmg  occurs  primarily, 
and  sometimes  only,  in  the  extensor  muscles  of  the  arm,  occasionmg 
the  well-known  wrist-drop.  It  generally  begins  m  the  extensor  com- 
munis, then  affects  the  radial  and  ulnar  extensors.  Gradually  other 
muscles  become  involved :  there  is  loss  of  power  in  the  ball  of  the 
thumb,  in  the  deltoid,  and  in  the  triceps,  but  not  in  the  supinator 
longus,  or  in  the  intercostal  muscles,  or  in  those  of  the  lower  extremi- 
ties. The  disturbed  muscles  on  both  sides  of  the  body  waste,  entirely 
lose  their  irritability  to  electricity,  and  soon  show  the  reaction  of 
degeneration.  The  patient  is  weak ;  his  movements  are  tremulous  ; 
he  has  the  characteristic  blue  line  on  the  gums,  is  obstinately  consti- 
pated, is  subject  to  colic,  and  lead  can  be  found  in  the  urine.  Some- 
times the  poison  seizes  upon  the  brain,  and  epileptic  convulsions  and 
other  signs  of  a  serious  cerebral  affection  appear,  and  we  find  marked 
optic  neuritis.  From  the  locality  of  the  palsy,  in  addition  to  the 
accompanying  symptoms  and  the  knowledge  of  the  man's  employ- 
ment, the  diagnosis  is  usually  arrived  at  with  ease.  Paralysis  pro- 
duced by  an  affection  of  the  radial  nerve  shows  the  greatest  simi- 
larity. Yet  here  the  supinator  muscles  as  well  as  the  extensors, 
but  upon  one  side  only,  are  affected,  which  is  not  the  case  in  lead 
paralysis,  where  both  sides  are  affected  and  the  patient  can  carry  the 
hands  supme.     Lead  palsy  may  be  met  with  in  children.-^ 

Diphtheritic  Paralysis. — Diphtheritic  paralysis  is  a  sequel  of 
diphtheria  which  follows  an  attack  of  the  disease  within  a  fortnight 
or  two  months,  and,  therefore,  after  the  patient  is  to  all  appearance 
fully  convalescent.  It  may  be  very  localized,  merely  affectmg  the 
palate  or  the  pharynx ;  or  very  general,  fastening  upon  both  of  the 
lower  extremities,  and  even' upon  the  upper.  When  extensive,  it  is 
ushered  in  by  a  change  in  the  voice  and  a  throat-palsy  ;  there  is  diffi- 
culty in  swallowing,  fluids  are  regurgitated  through  the  nose,  and  the 
saliva  dribbles  from  the  mouth.  Paralysis  of  accommodation  and 
strabismus  and  double  vision  are  not  uncommon.  The  paralysis  of 
the  extremities  ensues  gradually ;  day  by  day  the  muscular  power  is 
more  and  more  enfeebled.  The  loss  of  motion  is  often  preceded  by 
formication,  and  attended  by  a  certain  amount  of  anaesthesia.     The 


^  Cases  of  Sinkler,  Medical  News,  July,  1894. 


122  MEDICAL  DIAGNOSIS. 

faradic  electro-muscular  contractility  and  sensibility  are  diminished, 
and  the  galvanic  current  shows  mostly  the  same  results.  The  knee- 
jerks  may  be  abolished ;  and  the  gait  may  be  ataxic.  The  palsy 
mends  as  slowly  as  it  comes  on  ;  yet  most  cases  fully  recover.  The 
brain  itself  is  not  directly  affected  ;  at  least,  there  were  no  symptoms 
of  cerebral  mischief  in  the  cases  which  have  come  under  my  obser- 
vation. In  some  cases  rupture  or  plugging  of  a  cerebral  vessel  takes 
place.  Commonly  the  palsy  is  due  to  multiple  neuritis.  In  children 
affected  with  diphtheritic  paralysis  regular  bulbar  crises  may  happen,^ 

Syphilitic  Paralysis. — Not  unusually  the  syphilitic  exudation 
is  localized  in  the  course  of  one  or  of  several  nerves ;  we  have,  for 
instance,  paralysis  of  the  sixth  or  paralysis  of  the  fifth  with  or  with- 
out paralysis  of  some  other  cerebral  nerve.  But  as  syphilis  attacking 
the  nervous  system  is  chiefly  characterized  by  a  want  of  uniformity 
in  the  lesions  it  produces,  so  we  observe  dissimilar  phenomena,  pre- 
ceding or  attending  the  palsies.  Thus,  we  do  or  do  not,  though  in 
point  of  fact  we  usually  do,  find  the  paralysis  associated  with  pain  in 
the  head,  with  optic  neuritis,  with  sleeplessness,  vertigo,  impaired 
memory,  and  sickness  at  the  stomach.  Decided  vertigo  is  prone  to 
take  place  where  the  syphilitic  affection  has  led  to  disease  of  the  ves- 
sels, and  is  apt  to  be  the  forerunner  of  local  softening  and  of  hemi- 
plegia. When  disease  of  the  membranes  has  happened,  headache  is 
severe,  and  local  spasms  or  convulsions  occur.  The  same  symptoms 
are  encountered  when  there  is  a  growth  in  the  hemisphere,  which  is 
very  apt  to  be  near  the  surface ;  though  here  again  the  form  of  mis- 
chief may  be  comparatively  latent,  the  patient  may  have  only  occa- 
sionally convulsions,  and  the  paralysis  be  slight  or  improving,  yet  a 
fatal  coma  may  follow  a  few  convulsions.  Instances  of  this  have 
come  under  my  observation. 

But,  as  a  rule,  syphilitic  paralysis  does  not  terminate  fatally.  In 
truth,  the  ease  with  which  the  palsy  and  its  attending  phenomena 
mostly  yield  to  treatment,  forms  one  of  the  traits  of  the  malady. 
Other  common  features  are — that  it  ordinarily  affects  persons  younger 
than  those  in  whom  we  find  paralysis  dependent  upon  disease  of  the 
nervous  centres,  and  especially  of  the  brain ;  and  that  its  manifesta- 
tions are  shifting  and  capricious,  and  rarely  symmetrical.  These  same 
signs  characterize  syphilitic  affections  of  the  nervous  system  in  which 
paralysis  is  not  among  the  symptoms.  Paralysis  of  the  third  nerve 
is  a  frequent  result  of  syphilis  ;  -  but,  as  already  stated,  the  poison 

1  Guthrie,  Lancet,  April,  1891. 

2  Broadbent,  Lancet,  Jan.  1874. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD. 


123 


may  attack  any  part  of  the  nervous  system,  and  paraplegia  dependent 
upon  disease  of  the  cord  is  not  very  uncommon.  A  progressive 
multiple  palsy  of  cerebral  origin,  clearly  affecting  dissociated  muscles, 
is  usually  syphilitic,  and  is  mostly  due  to  several  patches  of  gum- 
matous meningitis.  At  times  a  rapid,  almost  universal  paralysis,  as 
Buzzard  notices,  occurs  in  syphilitic  subjects.  This  is  most  likely  of 
peripheral  origin.  It  is  among  the  peculiarities  of  syphilitic  palsy  that 
the  lost  electro-muscular  contractility  returns  rapidly.^ 

Erb  has  called  attention  to  an  association  of  symptoms  regarded 
as  characteristic  syj^hUis  of  the  cord.  They  come  on  gradually  at 
first,  but  may  then  rapidly  develop.  They  are  increased  reflexes,  with 
but  little  muscular  rigidity,  slight  spastic  gait  and  muscular  weakness, 
disorder  of  the  bladder  functions,  and  disturbances  of  sensation  in 
the  legs  in.  the  form  of  pareesthesia.     The  symptoms  are  confined  to 

below  the  waist. 

Fig.  14. 


Hutchinson's  teeth,  in  the  case  of  a  girl  eleven  years  of  age,  at  the  Pennsylvania  Hospital. 

In  syphilis  the  mischief  to  the  nervous  system  may  not  happen  for 
years  after  the  infection,  of  which  the  history  is  often  very  obscure. 
The  disorder  may  be  the  result  of  an  inherited  taint.  But  such  cases 
cannot  be  recognized  unless  there  are  other  signs  of  syphilis  than  the 
suspected  nervous  symptoms  ;  and  chief  among  these  signs  are  the 
evidences  of  periostitis  in  the  long  bones  and  of  disseminated  choroi- 
ditis in  the  fundus  of  the  eye.  Then  there  is  that  valuable  test  of 
congenital  syphilis  discovered  by  Mr.  Hutchinson, — a  malformation  of 
the  two  upper  central  permanent  incisors,  which  consists  in  their 
being  narrower  at  their  cutting  edges  than  at  their  insertions,  and 
often  notched.     The  same  observer  has  called  attention  to  diffused 


^  Engle,  Philadelphia  Medical  Times,  Dec.  1877. 


124  MEDICAL  DIAGNOSIS. 

opacity  of  the  cornea  and  to  diseased  nails  as  being  common  among 
the  maiiifestations  of  the  inherited  disease.  Paralysis  also  may  occur, 
as  in  the  case  reported  by  Bartlett ;  ^  but  it  is  very  rare. 

LOCAL   PALSIES. 

The  forms  of  paralysis  which  have  just  been  noticed  are  mainly 
such  as  are  designated  as  partial.  .  When  the  loss  of  power  is  very 
limited,  the  palsy  is  spoken  of  as  local;  most  of  these  local  palsies 
are  peripheral,  and  the  result  of  neuritis. 

Facial  Palsy. — Of  the  local  paralyses,  of  particular  importance 
from  its  frequency,  is  facial,  or  Bell's  palsy.  The  disease  consists 
in  an  affection  of  the  portio  dura  of  the  seventh  nerve.  In  conse- 
quence of  the  derangement  of  this  motor  nerve,  nearly  all  the  mus- 
cles of  one  side  of  the  face  lose  their  faculty  of  motion,  and,  as  it  is 
their  play  which  gives  expression  to  the  countenance,  the  appearance 
of  the  face  is  extraordinary.  The  eyelids  are  open  and  fixed ;  the 
features  are  rigidly  composed  on  one  side  of  the  face,  but  reflect  every 
change  of  feeling  on  the  other ;  the  mouth  is  distorted,  being  drawn 
to  the  unaffected  side  ;  the  naso-labial  fold  is  effaced ;  the  eye  waters  ; 
and  in  the  old  the  furrows  disappear  from  the  forehead.  In  some 
cases  the  velum  palati  is  mvolved  in  the  paralysis.  The  impaired 
muscles  waste ;  their  electric  irritability  is  diminished  and  degenera- 
tive reactions  may  be  present.  Sensation  remains  unaltered  so  long 
as  the  fifth  nerve  is  not  disturbed. 

The  causes  of  the  palsy  are  such  as  influence  the  distressed  nerve 
in  its  course  or  at  its  periphery :  a  wound ;  mumps  ;  ear-disease ; 
exposure  to  cold ;  rheumatism ;  syphilis.  The  most  common  cause 
is  a  neuritis  from  cold  affecting  the  nerve  within  the  Fallopian  canal. 
The  malady  is  easily  discriminated  from  the  facial  palsy  of  disease  of 
the  brain  by  the  inability  to  close  the  eyelids,  owing  to  the  paralysis 
of  the  orbicularis  palpebrarum ;  by  the  absence  of  headache,  of  ver- 
tigo, of  mental  confusion,  of  loss  of  memory ;  by  the  much  more 
complete  though  strictly  local  character  of  the  paralysis,  the  affected 
muscles  even  failing  to  participate  in  bilateral  or  emotional  move- 
ments ;  and,  except  in  slight  lesions  of  the  nerve,  by  the  lost  electro- 
muscular  contractility.  In  severe  cases,  indeed,  the  muscles  soon 
cease  to  respond  to  faradization,  while  the  galvanic  irritalDility  is  pre- 
served and  even  heightened,  and  the  reaction  of  degeneration  is  very 
marked.  Electric  stimulation  of  the  diseased  nerve  shows  that  it 
quickly  loses  its  excitability,  both  to  faradism  and  to  galvanism. 

^  Clinical  Society's  Transactions,  vol,  iii. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   COED.  125 

The  observations  of  Erb  enaUe  us  to  tell  with  considerable  accu- 
racy the  exact  part  of  the  nerve  affected.  They  take  into  account 
well-known  anatomical  and  physiological  facts,  and  lead  to  these 
conclusions.  If  there  be  complete  palsy  of  all  the  facial  branches 
with  the  exception  of  the  posterior  auricular  nerve,  the  lesion  is  in 
the  main  trunk  of  the  facial,  exterior  to  the  Fallopian  canal.  If  the 
auricular  nerve  be  also  implicated,  the  lesion  is  within  the  Fallopian 
canal  below  the  origin  of  the  chorda  tympani,  the  most  common  seat 
of  the  affection.  If  taste  and  salivary  secretion  be  disturbed  on  the 
side  of  the  tongue  corresponding  to  the  palsy  of  the  face-muscles, 
the  lesion  is  between  the  points  where  the  chorda  tympani  and  the 
tympanic  branch  are  given  off.  If  in  addition  the  sense  of  hearing 
be  abnormally  increased,  we  may  infer  that  the  nerve  is  affected 
between  the  tympanic  branch  and  the  geniculate  ganglion,  and  at 
the  latter  point  palsy  of  the  palate  is  superadded ;  and  higher,  up 
to  the  entrance  into  the  brain,  disorders  of  taste  happen.  Eventu- 
ally implication  of  other  cranial  nerves,  as  of  the  auditory,  also 
occurs. 

Cases  of  facial-ner\^e  palsy  generally  recover.  Sometimes,  how- 
ever, the  recovery  is  incomplete,  and  a  rigidity  with  some  contraction 
of  the  affected  muscles  takes  place,  which,  Avhen  slight,  may  make 
the  sound  side  appear  relaxed,  and  the  diseased  side  seem  the 
normal  one. 

In  rare  instances  the  facial  palsy  is  on  both  sides.  Now,  m  this 
double  facial  palsy  the  lesion  may  be  within  the  cranium,  such  as 
compression  by  a  tumor,  or  may  affect  the  nerves  while  passing 
through  the  medulla  and  pons  in  their  farther  course.  When  depend- 
ent simply  on  a  local  affection,  and  therefore  limited  to  the  manifes- 
tations of  paralysis  of  the  portio  dura,  we  find  the  same  causes  at 
work  which  give  rise  to  the  one-sided  disease.  Exposure  to  cold  and 
rheumatism  are  the  most  frequent ;  but  syphilis  is  also  among  them. 
In  an  instance  detailed  by  Todd,  in  which  there  was  disease  of  the 
temporal  bone,  the  portio  mollis  was  also  implicated.  The'  face  is 
immovable,  or  nearly  so,  and  the  palsy  is  generally  more  complete  on 
the  left  side  than  on  the  right.  The  muscles  do  not  respond  to  elec- 
tricity, or  respond  imperfectly,  and  we  notice,  as  in  the  one-sided 
malady,  that  a  continuous  current  may  excite  their  action,  while 
faradization  does  not.  Nay,  the  two  sides  may  give  different  results 
in  this  respect,^  most  likely  caused  by  different  conditions  of  exudation 
and  of  pressure  on  the  affected  nerves. 

^  Case  of  Baerwinkel,  Schmidt's  Jahrbuch,  Bd.  cxxxvi.  No.  1. 


126  MEDICAL  DIAGNOSIS. 

Paralysis  of  the  Nerves  of  the  Arm. — Paralysis  of  one  or 
more  nerves  of  the  arm  is  very  often  encountered.  It  may  happen 
from  rheumatism,  from  cold  developing  a  neuritis,  from  traumatism 
or  fracture,  or  from  the  pressure  of  a  growth ;  but  its  most  common 
cause  is  accidental  compression.  A  person  falls  asleep  with  his  head 
on  his  arm,  and  a  temporary  palsy  results  ;  or  it  may  follow  the  use 
of  a  crutch.  In  truth,  the  disorder  may  be  taken  as  the  type  of  the 
palsies  by  compression^  and  we  fmd  that  the  electro-muscular  contrac- 
tility depends  on  the  severity  of  the  nerve-lesion ;  as  a  rule,  there  is 
reaction  of  degeneration.  Sensory  symptoms  are  slight  or  wanting ; 
often  there  is  numbness  or  tingling. 

The  nerve  most  frequently  paralyzed  is  the  musculo-spiral,  or  its 
main  branch  the  radial,  and  we  observe  palsy  of  the  extensors  of  the 
wrist  and  the  fingers,  and  of  the  supinators.  In  the  loss  of  power 
in  these  muscles,  in  the  mode  of  onset,  and  in  the  unilateral  affec- 
tion we  fmd  the  differences  between  the  palsy  under  consideration 
and  the  wrist-drop  of  lead  palsy.  When  the  median  nerve  suffers, 
the  pronators,  the  radial  flexor  of  the  wrist,  the  flexors  of  the  fin- 
gers,— except  the  ulnar  half  of  the  deep  flexor, — the  abductor  and 
flexors  of  the  thumb,  and  the  first  and  second  lumbricales  are  para- 
lyzed ;  while  sensibility  is  impaired  or  lost  on  the  palmar  aspect  of 
the  thumb,  the  index  and  middle  fingers,  and  adjacent  portions  of 
the  ring-finger,  and  often  on  the  dorsal  aspect  of  the  last  phalanx  of 
the  index  and  middle  fingers. 

Involvement  of  the  ulnar  nerve  shows  itself  in  palsy  of  the  ulnar 
flexor  of  the  wrist,  the  ulnar  half  of  the  deep  flexor  of  the  fingers, 
the  muscles  of  the  little  finger,  the  interossei,  the  third  and  fourth 
lumbricales,  the  adductor  and  inner  head  of  the  short  flexor  of  the 
thumb ;  and  impairment  of  sensibility  in  the  parts  of  the  hand  and 
fingers  not  supplied  by  the  median  and  radial  nerves.  From  those 
diseases  of  the  spinal  cord  which  begin  with  arm  palsy,  the  local 
malady  is  distinguished  by  the  tenderness  in  the  course  of  the  nerve, 
and  the  one-sided  paralysis.  The  same  signs  separate  this  arm  palsy 
from  the  loss  of  power  in  the  wrists,  arising  from  atrophy  of  the 
muscles  in  the  overworked  parts,  occurring  in  undernourished  per- 
sons, as  in  poorly  fed  and  hard-worked  shoemakers.^ 

About  other  local  palsies,  as  of  the  pharynx  and  oesophagus,  of 
the  larynx,  of  one  side  of  the  palate,  of  the  tongue,  of  the  muscles  of 
the  eye,  of  the  diaphragm,  of  isolated  muscles  of  the  trunk,  and  of  the 
extremities,  it  is  impossible  here  to  enter  into  particulars.     But  there 

^  Chambers  on  the  Indigestions. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  127 

are  some  forms  of  local  palsy  which,  from  their  striking  interest,  it  is 
necessary  to  describe,  the  most  important  of  which  is  the  paralysis  of 
the  tongue  and  parts  concerned  in  deglutition. 

Bulbar  Paralysis. — Bulbar  palsy  can  scarcely  be  considered  a 
local  palsy.  It  has  a  close  relation  to  progressive  muscular  atrophy, 
yet,  from  a  clinical  point  of  view,  its  main  manifestations  are  those  of 
disorder  of  special  nerves.  In  this  bulbar  or  glosso-lahio-lai^yngeal 
paralysis,  the  first  symptoms  which  are  likely  to  attract  attention  are, 
that  the  tongue  seems  less  supple  and  the  utterance  becomes  nasal 
or  thick,  the  food  lodges  between  the  teeth  and  cheek,  and  the  saliva 
■dribbles  from  the  lips  and  corners  of  the  mouth.  As  the  paralysis 
progresses,  articulate  speech  is  almost  lost,  as  is  the  reflex  action  in 
the  throat ;  the  shape  of  the  tongue  is  altered,  it  generally  dwindles, 
and  at  times  shows  twitching  of  its  fibres,  or  lies  motionless  in  the 
mouth ;  the  posterior  nares  can  no  longer  be  closed  by  the  velum 
and  muscles  of  the  posterior  palatine  arch  ;  deglutition  becomes  very 
difficult,  and  the  patient  is  tormented  with  hunger.  Reflex  irrita- 
bility of  the  mucous  membrane  of  the  larynx  is  frequently  lost ;  the 
respiratory  movements  are  unusually  weak,  and  fits  of  suffocation 
ensue.  The  general  debility  becomes  extreme,  and  the  patient  is  apt 
to  perish  by  the  sudden  stoppag-e  of  the  heart's  action.  The  disease 
is  unmistakable.  Double  facial  palsy  resembles  it  most ;  but  here  the 
tongue  is  not  involved,  and  the  eyelids  remain  open ;  on  the  other 
hand,  in  bulbar  paralysis  the  loVer  part  of  the  face  only  is  motionless. 

This  condition  must  be  distinguished  from  so-called  pseudo-bulbar 
palsy,  depending  upon  bilateral  inflammatory  or  destructive  lesions 
of  the  cortical  centres  for  lips,  tongue,  and  pharynx,  or  their  centrif- 
ugal paths.  The  acuteness  of  onset,  perhaps  with  apoplectic  phe- 
nomena, the  absence  of  wasting  and  of  electrical  alterations,  and  the 
presence  of  other  symptoms,  such  as  hemiplegia  of  ordinary  or  of 
alternate  type,  differentiate  the  cerebral  from  the  bulbar  affection. 
Symptoms  of  bulbar  palsy  may,  however,  result  from  an  acute  lesion, 
such  as  hemorrhage,  inflammation,  or  softening  of  medullary  nuclei, 
and  be  sudden  in  onset.  The  chronic  affection  is  generally  of  rather 
slow  development  and  slow  but  relentless  progress ;  but  it  is  not 
nearly  so  chronic  a  malady  as  progressive  muscular  atrophy,  which 
may  last  from  ten  to  twenty  years,  while  the  bulbar  paralysis  has, 
like  lateral  sclerosis,  an  average  duration  of  from  one  to  three  years.^ 
Progressive  bulbar  paralysis  has  its  seat  of  lesion  in  the  medulla 
oblongata,  in  the  motor  nuclei,  which  undergo  a  degenerative  atrophy ; 

1  Mobius,  Schmidt's  Jahrbuch,  No.  2,  1882. 


128  MEDICAL  DIAGNOSIS. 

and  we  understand  the  main  symptoms  when  we  reflect  on  the 
nuclei  which  connect  the  hypoglossal,  the  spinal  accessory,  the  vagus, 
and  the  facial. 

Under  the  designations  myasthenia  gravis  pseudo-paralytica  and 
asthenic  bulbar  paralysis  a  condition  has  been  described  characterized 
by  weakness  of  voluntary  muscles,  especially  of  those  controlled  by 
the  bulbar  nerves,  or  by  undue  fatigue  after  ordinary  activity,  mthout 
wasting  or  without  changes  in  reflexes  or  in  sensibility.  Remissions 
and  exacerbations  are  common,  and  may  occur  suddenly.  The  affected 
muscles  respond  normally  to  electric  stimulation  except  that  to  tetan- 
izing  currents  the  response  grows  gradually  feebler  and  feebler.  The 
affection  is  believed  to  be  of  toxic  origin. 

With  reference  to  all  these  local  palsies  we  are  sometimes  much 
perplexed  to  know  if  the  palsy  be  the  result  of  beginning  disease  of 
the  brain  or  spinal  cord,  or  if  it  be  purely  local.  To  speak  first  of 
the  brain :  the  cerebral  symptoms  may  not  be  marked,  or  they  may 
be  so  contradictory  as  to  afford  no  real  help  in  diagnosis.  When, 
however,  we  discover,  as  we  generally  can,  that  the  palsy  affects 
muscles  which  are  supplied  by  different  nerv^es  and  such  as  have  no 
communication  with  one  another,  we  may  set  down  the  complaint  as 
having  a  central  origin.  As  regards  the  distinction  from  spinal  affec- 
tions, the  almost  constantly  single-sided  character  of  the  symptoms 
in  local  palsies,  and  their  double-sided  character  in  spinal  affections, 
are  very  important.  The  strikingly  symmetrical  kind  of  the  palsy 
and  the  element  of  pain  are  features  of  great  diagnostic  significance 
in  the  wide-spread  peripheral  paralyses  as  seen  in  multiple  neuritis. 

PALSIES   CONNECTED   WITH   MARKED   MUSCULAR   WASTING. 

There  is  a  group  of  palsies  especially  marked  by  wastmg  of  the 
muscles.  In  some  affections  already  discussed  we  have  found  wasting 
among  the  symptoms,  as  at  times  in  myelitis,  and  in  cervical  pachy- 
meningitis with  considerable  damage  to  the  nerve-roots,  where  atro- 
phy of  the  arms  happens.  Again,  atrophy  of  the  muscles  of  the 
trunk  and  limbs  is  often  met  with  in  the  advanced  stages  of  progres- 
sive bulbar  paralysis.  But  in  all  these  affections  there  are  more  dis- 
tinctive symptoms.  In  some  affections  the  waging  of  the  muscles  is 
the  pre-eminent  feature..  This  is  particularly  the  case  in  progressive 
muscular  atrophy  and  in  the  essential  paralysis  of  childhood. 

Progressive  Muscular  Atrophy. — This  form  of  "wasting 
palsy"  is  due  to  chronic  or  subacute  degenerative  changes  in  the 
gray  matter  of  the  anterior  horns  of  the  spinal  cord,  particularly  the 


DISEASES  OF  THE  BRAIN  AND   SPINAL   CORD.  129 

large  ganglion-cells,  sometimes  in  association  with  similar  changes  in 
the  peripheral  motor  nerves  and  the  pyramidal  tracts.  The  affected 
muscles  undergo  atrophy  of  varying  degree  and  extent. 

Progressive  muscular  atrophy  is  a  disease  of  adults,  and  essen- 
tially of  men  who  use  their  muscles  continuously  and  violently.  Its 
most  striking  sign  is  increasing  inability  to  perform  certain  move- 
ments. When  the  muscle  chiefly  concerned  in  the  attempted  motion 
is  examined,  it  is  found  to  have  dwindled.  Soon  other  muscles  fol- 
low ;  and  their  ^vasting,  too,  is  accompanied  by  further  muscular 
weakness.  The  disorganizing  muscles  twitch,  and  tapping  them 
sharply  causes  a  marked  contraction  of  the  fibres.  These  muscles 
of  the  face,  as  a  rule,  escape.  In  the  affected  part  the  circulation 
becomes  languid  ;  it  is  also  very  susceptible  to  cold,  and  its  temper- 
ature is  lowered ;  there  is  a  feeling  of  numbness  in  it,  but  rarely 
pain ;  to  pressure  it  is  soft  and  yielding.  The  muscles  most  fre- 
quently attacked  are  those  of  the  hand,  the  flexors  and  supinators  of 
the  forearm,  the  biceps,  the  deltoid,  and  the  other  muscles  of  the 
shoulder.  Sometimes  the  disease  begins  in  the  trunk  and  the  lower 
extremities  ;  but  it  is  most  common  to  have  it  marked  in  the  upper 
extremities  and  to  find  only  weakness  and  spasm  in  the  lower.  Some- 
times, also,  bulbar  symptoms,  with  weakness  of  the  muscles  of  the 
lips  and  tongue  and  of  the  pharynx  and  larynx,  appear,  and  changes 
are  found  in  the  medulla  analogous  to  those  present  in  the  cord.  The 
decrease  of  the  muscular  fibres  gives  rise  to  strange  and  palpable  de- 
formities, and,  when  the  muscles  of  the  trunk  are  involved,  to  ex- 
traordinary positions  of  the  body,  in  consequence  of  all  antagonism 
to  the  healthy  muscles  having  been  removed. 

In  the  parts  affected  the  reflex  action  is  lost ;  even  the  deep  re- 
flexes disappear.  We  see  this  happening  with  the  knee-jerk  just  so 
soon  as  the  muscles  of  the  legs  become  flaccid  and  begin  to  waste. 
To  the  electric  currents,  both  faradic  and  galvanic,  the  muscles  respond 
feebly ;  still  they  respond,  and  in  portions  where  there  are  many 
sound  fibres  they  contract  energetically.  The  degree  of  response  de- 
pends, indeed,  on  the  degree  of  disorganization  and  wasting.  Ex- 
citability to  the  galvanic  current  remains  much  longer  than  that  to 
faradization ;  the  reaction  of  degeneration  is  likely  to  be  present. 

From  cerebral  hemijjlegia  progressive  muscular  atrophy  differs  by 
its  much  more  gradual  invasion,  by  the  rapidity  but  want  of  uni- 
formity of  the  muscular  atrophy,  by  the  lost  reflexes,  by  the  dimin- 
ished electric  excitability,  and  by  the  absence  of  disordered  intellect 
and  of  other  signs  of  disease  of  the  brain.  Difficulty  in  articulation  and 
in  deglutition  may  occur  in  either.     From  general  sjnnal  paralysis  it  is 


130  MEDICAL  DIAGNOSIS. 

diagnosticated  by  the  spinal  malady  affecting  primarily  all  the  muscles 
of  the  lower  extremities  before  those  of  the  upper  become  involved. 
Then,  too,  if  the  spinal  paralysis  be  due,  as  it  so  generally  is  when 
extensive,  to  myelitis,  the  alterations  of  sensibility,  the  totally  lost 
electro-muscular  contractility,  and  the  affection  of  the  sphincters  are 
striking  traits  of  difference. 

The  difficulty  of  distinguishing  cases  of  local  paralysis  from  pro- 
gressive muscular  atrophy  is  at  times  very  great.  Yet  generally  we 
may  separate  the  latter,  for  instance  from  rheumatic  palsy,  by  no- 
ticing that  this  affects  a  group  of  muscles  rather  than  one  muscle, 
or  than  one  muscle  here  and  another  there.  Further,  the  atrophied 
muscle  in  the  rheumatic  disorder  is  the  seat  of  pain  intensified  by 
movement,  and  it  contracts  well  under  the  electric  stimulus.  The 
same  test  by  the  electric  current  is  of  service  in  discriminating  the 
muscular  disease  from  hysterical  paralysis,  and  from  paralysis  conse- 
quent upon  injuries  of  nerve-trunks  and  upon  lead  poisoning.  In  the 
first  of  these  palsies  the  electrical  contractility  is,  except  temporarily 
in  cases  of  old  standing,  intact,  in  the  others  it  is  abolished ;  in  pro- 
gressive muscular  atrophy,  save  when  the  wasting  is  extreme,  it  is 
simply  enfeebled.  Besides  this,  we  attach  importance  to  the  unim- 
paired sensibility,  the  capricious  and  unequal  manner  in  which  the 
atrophy  seizes  upon  the  muscles  in  this  malady,  the  fibrillation,  and 
the  beginning  of  the  wasting  in  the  thenar  muscles  and  the  inter- 
ossei. 

Hirst  ^  points  out  the  occurrence  of  muscular  atrophy  as  a  phenom- 
enon of  hysteria.  The  peculiarity  of  this  form  of  wasting  is  its  uni- 
lateral or  circumscrilDed  character,  though  sometimes  it  is  general. 
The  recognition  depends  upon  the  psychic  state  of  the  patient  and 
the  occurrence  of  hysterical  or  hystero-epileptic  convulsions. 

The  muscular  atrophy  due  to  degeneration  of  the  anterior  horns 
of  the  spinal  cord  differs  from  that  due  to  multiple  neuritis  in  its 
progressive  rather  than  retrogressive  character,  but  especially  in  the 
absence  of  symptoms  of  sensory  derangement. 

The  most  difficult  differential  diagnosis  we  may  be  called  upon  to 
make  is  to  distinguish  certain  cases  of  progressive  muscular  atrophy 
from  bulbar  paralysis.  In  truth,  the  two  affections  often  coexist. 
The  diagnosis  depends  upon  the  distribution  of  the  symptoms,  the 
morbid  process  being  essentially  the  same  in  the  two  sets  of  cases. 
In  the  one  the  arms,  and  sometimes  also  the  legs,  suffer ;  in  the 
other  the  tongue,  the  lips,  the  pharynx,  and  the  larynx.     Defective 

1  Deutsche  Medicinisclie  Wochenschrift,  1894,  No.  21,  p.  459. 


DISEASES  OF  THE  BKAIN  AND  SPINAL  CORD.  131 

pronunciation  points  to  the  bulbar  malady.  Failure  of  the  respira- 
tory power  is  common  to  both. 

Local  atrophies  may  be  mistaken  for  part  of  the  general  disease. 
There  is,  for  instance,  an  affection,  unilateral  progressive  atrophy  of  the 
face,  in  which  gradual  wasting  of  one  side  of  the  face  occurs,  of  the 
soft  parts  first,  and  then  of  the  deeper  tissues.  The  facial  hemiatrophy 
follows  blows  and  contusions,  abscess  of  the  ear,  influenza,  typhoid 
fever,  or,  as  in  Cohen's  case,  an  attack  of  erysipelas.  It  begins  with 
a  discoloration  of  circumscribed  spots,  a  white  or  yellowish  discolor- 
ation ;  the  subcutaneous  fat  disappears,  and  the  beard  and  eyelashes 
change.  Sensation  is,  as  a  rule,  not  affected,  nor  are  the  electrical 
reactions  changed.^  But  in  progresssive  muscular  atrophy  the  face 
almost  always  escapes  ;  if  it  be  affected,  it  is  so  on  both  sides.  Acute 
or  chronic  joint-inflammations  are  attended  with  weakness  and  wasting 
of  the  muscles  moving  the  affected  parts.  The  extensors  usually 
suffer,  occasionally  also  the  flexors,  and  rarely  distant  muscles.  An- 
other limited  atrophy  is  a  wasting  from  overuse  of  muscles,  seen  es- 
pecially in  the  small  muscles  of  the  hand.  It  shows  no  tendency  to 
extend. 

Paralyzed  muscles  atrophy,  and  may  subsequently  undergo  de- 
generative change ;  but  the  distribution  differs  from  that  of  pro- 
gressive muscular  atrophy,  and  we  lay  stress  on  the  symptoms  that 
usher  in  and  that  attend  the  paralytic  state. 

In  the  condition  known  as  syringomyelia,  in  which  the  central  gray 
matter  of  the  spinal  cord  is  replaced  by  gliomatous  tissue  that  breaks 
down  and  gives  rise  to  the  formation  of  a  cavity,  we  have  fibrillar 
contractions  in  the  affected  muscles  and  atrophy,  with  resulting  de- 
formities. But  symptoms  of  sensory  derangement  appear  earlier  and 
are  more  pronounced.  Common  sensibility  is  generally  unchanged, 
where  there  is  inability  to  distinguish  heat  and  cold,  and  often  also  to 
appreciate  pain.  The  sphincters  are  not  disturbed  ;  the  knee-jerks  are 
normal  or  exaggerated.  The  muscles  waste,  rapidly  lose  their  faradic 
excitability,  and  the  reaction  of  degeneration  is  finally  established. 
The  symptoms,  on  the  whole,  are  of  slow  development,  and  show 
themselves  chiefly  in  the  arms  and  in  the  upper  part  of  the  trunk. 
There  is  unsteadiness  of  motion,  with  muscular  weakness  rather  than 
paralysis,  and  trophic  disturbances'  in  the  skin,  such  as  thickenings, 
eruptions,  ulcerations,  are  marked  ;  so  are  arthropathies.     In  the  legs 

^  See  eases,  Journal  of  Nervous  and  mental  Diseases,  New  York,  March,  1880  ; 
Schmidt's  Jahrbuch,  No.  7,  1881  ;  St.  Louis  Alienist,  April,  1881  ;  and  Skyrme, 
Brit.  Med.  Journ.,  March,  1892. 


132  MEDICAL  DIAGNOSIS. 

there  may  be  spastic  paresis.  Inequality  of  the  pupils  and  nystagmus 
are  not  unusual.  Deviation  of  the  spine  is  common ;  it  was  present 
in  half  the  cases  analyzed  by  Bruhl.^  A  large  number  of  cases  origi- 
nate in  injuries  to  the  back.^  A  case  presenting  symptoms  of  syringo- 
myelia has  been  recorded  in  which  after  death  gummata  were  found 
on  either  side  of  the  brachial  enlargement  of  the  cord.^ 

The  disorder  described  by  Morvan  and  called  by  his  name,  and 
also  "  painless  whitlows,"  presents  symptoms  of  syringomyelia  in 
conjunction  with  those  of  peripheral  neuritis.  At  first  there  may  be 
neuralgic  pains  in  the  hands,  followed  by  anaesthesia  and  muscular 
wasting,  and  the  formation  of  whitlows  that  undergo  ulceration,  and 
are  attended  with  necrosis  of  the  phalanges.  The  altered  vasomotor 
condition  is  also  shown  by  the  elevation  of  temperature  in  the  weak- 
ened limbs,  the  red  spots  or  the  intense  flushing  of  the  surface,  and 
the  ease  with  which  the  skin  blisters. 

There  is  another  disease  resembling  progressive  muscular  atrophy 
which  may  be  here  mentioned,  the  singular  affection  endemic  in  parts 
of  Japan,  known  there  as  kaJcke,  and  probably  identical  with  the 
disease  called  in  India  and  Brazil  beriberi.  The  generally  accepted 
view  is  that  beriberi  is  an  infectious  disease,  developing  under  con- 
ditions of  high  temperature  and  moisture,  and  presenting  the  symp- 
toms of  a  multiple  neuritis.  Observations  made  in  Japan  render  it 
likely  that  the  cause  of  the  neuritis  is  generally  poisoning  by  damaged 
rice,  and  it  is  said  that  attention  to  the  diet  has  almost  banished  the 
disease  from  the  Japanese  navy.^  It  has  also  been  thought  to  be  due 
to  absence  of  fat  from  the  dietary.  Four  types  of  the  malady  are 
recognized, — an  incompletely  developed  or  rudimentary  form ;  an 
atrophic  form  ;  a  dropsical  form,  with  or  without  atrophy ;  a  perni- 
cious or  cardiac  form.  The  most  conspicuous  symptoms  are  impair- 
ment of  motion,  with  wasting  and  diminution  in  mechanical  and  elec- 
trical irritability,  sensory  changes,  circulatory  disturbances,  alDolition 
of  the  knee-jerks,  diminished  secretion  of  urine,  and  albuminuria. 

A  form  of  progressive  muscular  atrophy,  known  as  the  peroneal 
type,  and  described  by  Charcot,  Marie,  and  Tooth,  usually  sets  in  early 
in  life,  affecting  first  the  muscles  of  the  foot  and  leg,  sometimes  those 
of  the  hand  and  forearm,  and  extending  upward.  In  addition  to 
weakness  and  wasting,  sensation  is  deranged  and  degenerative  elec- 

^  Etude  de  la  syringomyelie,' Paris,  1890. 
^  Guy  Hinsdale,  Syringomyelia,  Philadelphia,  1897. 
^  Beevor,  Lancet,  vol.  ii.,  1893,  p.  1262. 

*  Takaki,  Report  of  the  Japanese  Navy,  1886,  quoted  in  Sajous's  Annual,  vol. 
i.,  1888. 


DISEASES  OF  THE  BRAIN  AND   SPINAL   CORD.  133 

trie  reactions  are  present.  The  condition  is  dependent  upon  neuritis 
and  it  occurs  in  families.     Club-foot  is  a  common  resulting  deformity. 

It  is  sometimes  a  matter  of  extreme  difficulty  to  distinguish  cases 
of  what  are  called  progressive  muscular  dystrophy,  where  there  is  no 
appreciable  central  nervous  lesion,  from  the  progressive  muscular 
atrophy  under  consideration.  When  the  former  disease  happens  in 
children  the  distinction  is  not  so  difficult ;  for  the  age,  and  the  circum- 
stance that  not  infrequently  several  members  of  the  family  are  affected, 
in  some  of  whom  it  may  assume  the  pseudo-hypertrophic  form,  show 
what  it  is.  But  in  adults  there  may  be  great  uncertainty.  The  ex- 
tremely slow  progress  of  the  disease  ;  its  not  unusual  beginning  in 
childhood ;  the  fact  that  the  muscles  of  the  forearm  and  hand  escape, 
as  a  rule,  while  the  face  is  sometunes  involved,  as  well  as  the  latis- 
simus  and  the  lower  half  of  the  pectoralis,  that  it  affects  males  far 
more  commonly  than  females,  and  that  it  is  congenital,  are  some  of 
the  characteristic  points.  Fibrillary  twitching  of  the  muscles  is  want- 
ing, the  deep  reflexes  are  enfeebled,  and  the  electric  reactions  un- 
dergo only  quantitative  diminution  proportionate  to  the  degree  of 
wasting. 

Several  types  of  the  disease  have  been  described,  the  idiopathic^ 
the  pseudo-hypertrophic,  the  juvenile  or  scapulo-humeral,  the  infantile  or 
facio-scapido-humeral,  and  the  hereditary,  but  the  distinctions  are  not 
readily  mamtained.  All  present  in  common  hereditary  or  family 
distribution,  onset  early  in  life,^  preponderance  among  males,  progres- 
siveness  of  course,  weakness  and  wasting,  sometimes  preceded  by 
apparent  hypertrophy  of  various  muscles,  lessening  of  mechanical 
and  electric  irritability  and  of  deep  reflexes.  The  gait  is  peculiarly 
waddling,  and  extraordinary  attitudes  are  assumed  in  attempting  to 
rise  from  the  ground.  The  lesions  in  the  muscles  consist  in  increase 
in  size  of  some  fibres,  with  diminution  of  others,  degenerative  changes, 
and  more  or  less  increase  in  the  interstitial  connective  and  fatty  tis- 
sues. The  wasted  muscles  undergo  shortening  and  contraction,  and 
various  deformities  result.  The  function  of  the  sphincters  is,  as  a  rule, 
preserved  ;  intelligence  is  not  affected  ;  and  sensibility  is  unimpaired. 

Infantile  Paralysis. — In  this  disease,  also  known  as  essential 
paralysis  of  children,  and  acute  anterior  poliomyelitis,  rapid  wasting 
of  the  muscles  is  the  striking  feature.  It  is  pre-eminently  an  affection 
of  early  childhood,  and,  as  shown  by  Wharton-Smkler^  occurs  much 


^  Destarac,  La  Medecine  Moderne,  1894,  No.  89,  p.  1387,  has  reported  a  case 
of  pseudo-hypertrophic  paralysis  in  a  man  sixty-eight  years  old,  without  heredi- 
tary predisposition. 


134  MEDICAL  DIAGNOSIS. 

more  commonly  in  summer  than  in  winter.  It  happens  most  fre- 
quently during  the  first  dentition,  and  is  often  ushered  in  by  fever,  by 
diarrhoea,  nausea  or  vomiting,  and  by  convulsions.  The  palsy  comes 
on  quickly,  generally  before  the  fever-disturbance  has  passed  away ; 
or  an  entire  limb,  or  even  both  legs  and  arms,  may  almost  from  the 
onset  be  affected.  In  any  case  the  palsy  becomes  plainly  discernible 
as  the  fever  subsides.  It  is  apt  to  begin  in  one  limb  and  m  a  few 
days  to  become  mde-spread.  But  it  disappears,  except  from  a  par- 
ticular region  in  which  the  muscles  quickly  waste. 

Yet  the  palsy  may  at  first  shift ;  it  passes  away  from  some  limbs, 
or  fixes  upon  others  or  upon  different  groups  on  different  sides  of  the 
body.  It  rarely,  however,  remains  as  palsy  of  more  than  one  side, 
and  is  not  associated  with  loss  of  sensibility.  There  is  often  decided 
recovery  within  six  months  from  the  onset  of  infantile  paralysis ; 
although  some  loss  of  power  may  be  permanent.  The  affected  mus- 
cles are  apt  to  begin  to  atrophy  after  the  paralysis  has  lasted  a  month, 
and  when  thefr  wasting  is  marked  they  no  longer  resjDond  to  the  fa- 
radic  current,  though  they  may  still  react  strongly  under  the  galvanic 
current ;  but  gradually  this  excitability,  too,  is  lost.  Both  the  super- 
ficial and  tendon  reflexes  are  lowered  or  abolished.  After  six  months 
or  a  year  some  faradic  frritability  is  apt  to  return.  The  functions  of 
the  bladder  and  rectum  are  very  seldom  affected.  In  protracted 
cases,  permanent  shortening  of  muscles  happens,  contraction  of  the 
joints  takes  place,  and  atrophy  of  portions  of  the  osseous  system 
occurs,  or  rather  a  want  of  its  development  in  the  blighted  parts,  and 
various  and  striking  deformities  result. 

Now,  the  onset  of  these  cases,  the  febrile  symptoms,  the  occasional 
retrocession  from  certain  parts,  and  the  subsequent  course,  separate 
infantile  paralysis  from  progressive  muscular  atrophy.  Then  in  form- 
ing a  diagnosis  we  may  take  into  account  the  extreme  rarity  with 
which  children  are  attacked  mth  progressive  muscular  atrophy.  Yet 
the  affection  may  happen  in  children,  and  then,  as  Duchenne  pointed 
out,  is  apt  to  show  itself  first  in  the  muscles  around  the  mouth.  On 
the  other  hand,  we  must  not  forget  that  a  disease  identical  with  the 
essential  palsy  of  children  is  met  with  m  adults.  Beginning  acutely 
with  febrile  symptoms,  headache,  clelfrium,  vomiting,  and  rheumatoid 
pain  in  the  back,  it  leads  within  a  few  days  or  less  to  palsy  with  com- 
plete relaxation  of  the  paralyzed  muscles,  yet  without  impaired  sensi- 
bility ;  exhibits  but  passmg  vesical  disorder ;  but  shows  soon  disap- 
pearance of  reflex  irritability  and  wasting  of  the  limbs,  with  or  without 
paralytic  contractions,  lost  electro-muscular  contractility,  and  has  the 
lesion  which  has  been  found  in  infantile  palsy, — granular  degeneration 


DISEASES  OF  THE  BEAIN  AND  SPINAL   CORD.  135 

of  the  cells  of  the  anterior  horns.  With  reference  to  this  acute 
atrophic  spinal  paralysis  or  acute  anterioo- poliomyelitis,  we  have  learned 
that  often  complete  or  nearly  complete  recovery  from  the  threatening 
symptoms  takes  place,  and  that  it  is  probably,  due  to  a  systemic 
infection. 

From  the  foregoing  remarks  it  might  be  inferred  that  children  are 
only  subject  to  palsies  that  are  spinal.  But  this  is  not  the  case.  We 
find  in  them  a  whole  group  of  cerebral  palsies, — not  nearly  so  frequent, 
it  is  true,  as  the  spinal  group,  but  palsies  in  which  the  lesion  is  cere- 
bral, extending  from  any  part  of  the  cortex  to  the  pyramidal  tracts  of 
the  cord,  and  broadly  distinguished  from  the  spinal  palsy  by  height- 
ened reflexes,  unchanged  electrical  reactions,  loss  of  power  with  dis- 
ordered movements  or  spasm,  and  retarded  growth  of  the  affected 
parts.  We  may  find  either  hemiplegia,  bilateral  hemiplegia,  or  para- 
plegia as  the  form  of  paralysis.  In  some  instances  the  affection  fol- 
lows delivery  with  the  forceps ;  like  spinal  infantile  palsy,  it  has  been 
observed  after  infectious  diseases.  Under  the  first  condition  it  is 
probably  due  to  meningeal  hemorrhage ;  under  the  second,  to  either 
hemorrhage  into  brain  or  membranes,  or  to  vascular  occlusion. 
Sometimes  the  disease  begins  with  fever  accompanied  by  convulsions  ; 
these  may  be  followed  by  marked  coma.  The  hemiplegia  is  most 
persistent  m  the  arm,  and  is  apt  to  be  associated  with  spastic  con- 
traction, producing  a  peculiar  gait.  Post-hemiplegic  chorea  and 
mobile  spasm  and  athetosis  were  observed  m  a  considerable  number 
of  cases  analyzed  in  Osier's  elaborate  monograph.^  Convulsive 
seizures  on  the  paralyzed  side  or  general  epilepsy  are  yet  more  com- 
mon, and  the  intelligence  is  enfeebled. 

In  the  bilateral  form  of  hemiplegia  the  legs  are  more  involved 
than  the  arms  ;  spastic  contractions  of  the  muscles  of  the  extremities 
are  most  marked ;  the  mind  is  very  much  affected ;  sensation  is  not 
disordered.  Destruction  of  the  motor  centres  of  the  cortex  is  the 
essential  lesion  m  bilateral  spastic  hemiplegia.^  In  the  spastic  cerebral 
paraplegia  of  children  McNutt  ^  found  descending  degeneration  in  the 
pyramidal  tracts ;  the  disease  is  limited  to  the  lower  extremities ; 
there  is  no  muscular  wasting  ;  the  gait  is  stiff'  or  cross-legged.  The 
malady  usually  exists  from  birth,  and  follows  a  difficult  labor.     The 

^  The  Cerebral  Palsies  of  Children,  1889.  See,  also,  Sachs  and  Peterson, 
Study  of  Cerebral  Palsies  of  Early  Life,  based  upon  one  hundred  and  forty  cases. 
Journal  of  Nervous  and  Mental  Diseases,  May,  1890;  and  Sachs,  Samnil.  Klin. 
Vortr.,  No.  46,  1892. 

^  Osier,  op.  cit. 

^  Amer.  Journ.  Med.  Sci.,  vol.  i.,  1885. 


136 


MEDICAL  DIAGNOSIS. 


intellect  is  impaired,  though  not  always  markedly  so.  Wood  ^  states 
the  affection  to  be  the  result  of  sclerotic  and  atrophic  changes  in  the 
brain. 


Before  proceeding,  we  will  examine  the  main  forms  of  paralysis 
which  we  have  been  studying,  arranged  in  a  tabular  form,  and  chiefly 
with  the  view  of  ascertaining  the  seat  of  lesion,  premismg  that  the 
statements  must  be  received  rather  as  generally  true  than  as  abso- 
lutely so. 

TABULAR   VIEW   OF   PARALYSIS. 


Symptoms. 
Inability  to  move  leg  and  arm  of  one 
side.  Sensation  unimpaired,  unless 
posterior  third  of  posterior  limb  of 
capsule  involved.  Paralysis  of  mus- 
cles of  lower  part  of  face  ;  mouth 
drawn  towards  healthy  side.  Elec- 
tro-muscular contractility  preserved. 
Reflex  excitability  of  the  tendons 
exaggerated. 

Same  symptoms,  dependent  on  involve- 
ment of  internal  capsule.  Mobile 
spasm  and  incoordination  in  para- 
lyzed parts. 


Seat  of  Lesion. 
Corpus  striatum,  involving  internal  cap- 
sule,   both   on   side    opposite   to    the 
palsy. 


Optic  thalamus. 


Same  symptoms,  but  paralysis  of  face, 
with  antesthesia,  on  opposite  side  to 
that  of  arm  and  leg,  and  usually 
marked  ;  conjugate  paralysis  or  spasm 
of  eyes  ;  difficulty  in  deglutition  and 
articulation.  Heightened  tempera- 
ture ;  convulsions  ;  contracted  pupil. 
Urine  may  contain  sugar  or  albumin. 
Early  rigidity  of  paralyzed  muscles. 

Same  symptoms,  but  face  paralyzed  on 
both  sides. 


Pons  Varolii,  on  side  opposite  to  palsy 
of  limbs.  The  part  affected  is  below 
decussation  of  facial  nerve. 


Pons  Varolii,  and  at  level  of  decussation 
of  facial  nen-e. 


Paralysis  of  arm  and  leg  and  lower  part 
of  face  on  one  side  ;  third  nerve  para- 
lyzed on  other  side  ;  defective  sensa- 
tion ;  vasomotor  disturbance. 


Crus    cerebri    on  side   corresponding   to 
paralysis  of  third  nerve. 


Nervous  Diseases  and  their  Diagnosis. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD. 


137 


TABULAR   VIEW   OF   PARALYSIS.— Co/i^mwerf. 


Symptoms. 
Paralysis  of  motion  of  face,  arm,  or  leg, 
soon  followed  by  rigidity  ;    sensation 
may   be   impaired.     Reflexes,    super- 
ficial   and    deep,    increased.     Convul- 


Seat  of  Lesion. 
Cortical  part  of  brain  in  motor  zone  on 
side  opposite  to  palsy. 


Motion  more  or  less  completely  affected 
on  both  sides  of  body,  except  in  face  ; 
paralysis  of  hypoglossal,  glosso- 
pharyngeal, and  spinal  accessory 
nerves  ;  often  rapidly  fatal. 

Both  legs  and  lower  part  of  trunk  para- 
lyzed as  to  motion  ;  loss  of  sensation  ; 
some  wasting  of  muscles  ;  loss  of 
power  OA'er  bladder  and  rectum  ;  re- 
flex excitability  in  legs  heightened, 
trunk  reflexes  impaired  ;  electric  con- 
tractility diminished  or  lost ;  trophic 
changes ;  paralysis  of  muscles  of  res- 
piration in  some  instances. 

Both  legs  paralyzed,  muscles  of  legs 
flaccid  ;  feet  extended  ;  anaesthesia  ; 
incontinence  of  urine  from  the  start. 
Superficial  and  deep  reflexes  lost. 
Rapid  wasting  of  muscles.  Reaction 
of  degeneration.     Trophic  changes. 

Arms  as  well  as  legs  paralyzed  ;  arms 
flaccid,  legs  spastic  ;  otherwise  symp- 
toms much  the  same  ;  affection  of 
pupils. 

Paralysis  irregular  in  degree  and  dis- 
tribution, relaxation  of  muscles,  sen- 
sation unimpaired,  only  transient  loss 
of  control  over  bladder  and  rectum  ; 
marked  lowering  or  extinction  of  re- 
flex excitability  in  the  palsied  muscles 
and  tendons ;  lost  electro-muscular 
contractility  to  faradic  current ;  usually 
reaction  of  degeneration ;  rapid  mus- 
cular atrophy  ;  no  bedsores  ;  if  dis- 
ease become  chronic,  muscular  con- 
tractions. 


Medulla  oblonsata. 


In  the  cord  throughout  its  section  above 
the  lumbar  enlargement,  as  in  trans- 
verse myelitis  of  the  dorsal  cord. 


In  the  cord  in  lumbar  enlargement,  as 
seen  in  myelitis  of  these  parts. 


Cervical   region  of  the  cord,   as  in  cer- 
vical myelitis. 


Anterior  horns  of  the  cord,  as  in  de- 
generation of  the  cells  in  acute  polio- 
mvelitis. 


9 


138  MEDICAL   DIAGNOSIS. 

Ataxia. 

Loss  of  co-ordination  of  muscular  movement,  which  in  the  legs 
shows  itself  especially  in  the  gait,  and  in  the  hands  in  the  difficulty 
of  executing  delicate  movements,  but  which  strangely  contrasts  with 
the  muscular  power  that  is  present,  is  found  in  general  paralysis  of 
the  insane,  multiple  neuritis,  and  diphtheritic  paralysis.  But  the 
ataxia  is  most  constant  and  marked  in  locomotor  ataxia. 

Locomotor  Ataxia. — In  this  disorder  we  have  uncertainty  of 
motion  and  seeming  palsy ;  or,  in  the  words  of  Duchenne,  who  gave 
it  the  name  of  progressive  locomotor  ataxia,  it  consists  in  "  a  pro- 
gressive abolition  of  the  co-ordination  of  movement  with  apparent 
paralysis  contrasting  with  the  integrity  of  muscular  force."  The 
patient  is  not  deprived  of  the  power  of  motion,  but  of  the  power  of 
controlling  his  motion :  hence  he  staggers  in  his  walk,  or  cannot  walk 
at  all  without  support ;  the  muscles  are  obedient  to  the  will,  but  the 
peripheral  impressions  by  which  motor  impulses  are  guided  are  im- 
properly or  imperfectly  conveyed. 

Locomotor  ataxia  is  identical  with  a  form  of  palsy  clearly  recog- 
nized by  Todd,  and  with  the  malady  described  by  Romberg  as  tahes 
dorsalis;  from  the  lesion  it  exhibits,  it  is  often  called  posterior  scle- 
rosis, degeneration  of  the  posterior  columns  of  the  cord,  and  of  the 
posterior  nerve-roots  being  its  main  cause.  A  wasting  of  the  nerve- 
fibres  of  the  peripheral  spinal  sensory  nerves  has  also  been  found. 

The  affection  is  a  very  chronic  one,  lasting  many  years.  It  is  a 
disease  of  adult  life,  and  it  occurs  far  more  commonly  in  men  than  in 
women.  It  may  originate  without  assignable  cause,  or  may  follow 
alcoholic  excess,  or  exposure  to  cold,  or  injury  or  inflammation  of 
the  cord,  or  is  hereditary.  It  has  been  observed  to.  follow  pernicious 
anaemia.^  It  is  most  frequently  found  to  be  associated  with  a  history 
of  syphilis.  Among  its  early  symptoms  are  piercing  pains,  lightning- 
like or  similar  to  electric  discharges,  in  the  lower  extremities  ;  en- 
feeblement  or  loss  of  knee-jerk ;  disordered  gait ;  diplopia  or  other 
disturbances  of  vision,  which  may  be  attended  with  the  "Argyll- 
Robertson  pupil," — a  small  pupil  that  does  not  respond  to  light,  but 
does  respond  to  accommodation, — or  with  paralysis  of  the  sixth  or 
the  third  pair  ;  and  a  zone  in  which  sensation  is  greatly  impaired  on  a 
level  with  the  third,  fourth,  fifth,  or  sixth  dorsal  vertebra.^ 

^  Putnam,  Amer.  Journ.  Med.  Sci.,  March,  1895  ;  also  Burr,  University  Medical 
Magazine,  April,  1896. 

^  Hitzig,  in  Ziemssen's  Cyclopaedia,  article  "Atrophy  of  Brain." 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  139 

Following  these  phenomena,  or  making  its  appearance  with  them, 
is  a  difficulty  in  co-ordinating  movements  and  in  maintaining  the 
equilibrium  of  the  body.  It  is  manifest  in  attempting  to  walk  with 
the  eyes  closed  or  in  the  dark  ;  and  the  patient  is  unable  to  take  a 
step,  or  to  stand  erect  with  his  feet  in  juxtaposition,  without  swaying 
and  losing  his  balance.  This,  the  so-called  Romberg  symptom,  is  not 
pathognomonic,  but  it  is  very  valuable  in  the  diagnosis  of  the  earlier 
stages,  and  so  is  the  difficulty  in  placing  the  foot  on  small  surfaces, 
in  buttoning  the  clothes,  or  in  walking  backward.  Nor  can  the 
patient  stand  upon  his  toes,  or  upon  one  foot.  Another  symptom  is 
FraenheVs  symptom,  or  hypotonia,  the  power  to  straighten  the  legs 
completely  when  at  right  angles  to  the  body. 

Yet  the  stumbling  gait  is  not  connected  with  true  paralysis.  The 
muscles  can  act  vigorously,  are  well  nourished,  contract  readily  when 
faradized,  except  in  advanced  stages  of  the  disease,  and  show  neither 
tremor  nor  spasm.  The  feet,  in  walking,  are  raised  high  in  air  and 
brought  down  upon  the  heel  or  upon  the  whole  sole.  The  cutaneous 
reflexes  are  generally,  yet  not  always,  impaired ;  there  is  absence  of 
the  patellar  tendon  reflex  in  both  knees.  Sensibility  is  markedly 
diminished,  pinching  and  pricking  the  foot  may  scarcely  be  felt,  con- 
tact with  the  floor  may  not  be  appreciated,  perception  of  sensory  im- 
pressions may  be  delayed,  girdle-sense  is  often  present,  and  the  tactile 
sensibility  may  be  almost  gone ;  but  all  kinds  of  curious  sensations- 
are  complained  of.  The  power  to  appreciate  differences  of  tempera- 
ture may,  though  it  does  not  always,  remain,  and  there  is  a  delay  in 
the  perception  of  pain.  The  muscles,  too,  lose  their  sensibility.  It 
is  not  unusual  to  have  pains  in  the  region  of  the  fifth  nerve.  The 
intellect  is  unimpaired,  unless  frequent  attacks  of  vertigo  and  epileptic 
seizures  should  be  among  the  symptoms.  The  eyesight  fails  more 
and  more,  there  is  loss  of  color-vision,  and  an  atrophy  of  the  optic 
nerve  may  produce  irremediable  loss  of  sight ;  the  hearing,  too,  may 
become  much  affected ;  and  signs  of  valvular  disease  of  the  heart, 
especially  of  the  aortic  valve,  show  themselves.  The  functions  of  the 
rectum  and  bladder  are  not  markedly  disordered,  though  retention  of 
urine  and  sluggish  action  of  the  bladder  are  not  infrequent.  The 
sphincter  ani  is  often  weak,  but  constipation  is  common.  There  is 
loss  of  sexual  power.  Dropsy  and  local  sweating  are  met  with,  and 
so  is  swelling  of  the  joints,  without  redness  and  usually  without 
pain. 

But  the  joint  affection  may  appear,  as  Charcot  has  taught  us,  be- 
fore the  loss  of  power  of  co-ordinating  movement.  In  time,  it  may 
be  rapidly,  the  articular  extremities  of  the  bones  disappear,  and  the 


140  MEDICAL   DIAGNOSIS. 

joints  undergo  a  kind  of  dislocation.  Tlie  shafts  of  tlie  bones,  too, 
show  defects  of  nutrition,  and  spontaneous  fractures  happen.  The 
teeth  drop  out  of  the  atrophied  alveolar  processes,  and  so  may  parts 
of  the  bones  themselves  ;  ^  the  tendons  tear  ;  the  tongue  may  d^vindle 
on'  one  side ;  the  spine  becomes  curved.  Herpetic,  bullous,  and 
pemphigoid  eruptions  or  ecchymoses  may  appear  during  or  subse- 
quent to  exacerbations  of  the  lightning  pains.  Perforating  ulcer  of 
the  foot  has  also  been  obser^^ed  among  the  tropliic  changes. 

Among  some  of  the  less  common  symptoms  is  drooping  of  the 
eyehds,  accompanied  by  weakness  of  all  the  muscles  attached  to  the 
eyeball,  and  a  sense  of  the  face  being  covered  by  a  mask.-  Another 
symptom,  more  frequent,  is  the  occurrence  of  spasms  and  pain  in 
the  epigastric  region,  with  attacks  of  vomiting.  These  gastric  crises, 
as  they  have  been  termed,  may  be  found  to  happen  in  those  who 
complain  much  of  fulness  in  the  abdomen  and  of  unsatisfied  hunger. 
They  have  even  been  known  to  lead  to  vomiting  of  blood.  Buzzard^ 
shows  the  symptoms  to  be  dependent  upon  sclerosis  affecting  the 
nucleus  of  the  vagus.  There  is  always  in  these  gastric  crises  acid 
fermentation,  but  hydrochloric  acid  is  also  constantly  found.*  There 
are  at  times  attacks  of  laryngeal  spasm  in  ataxics.  Arthropathies 
often  happen  in  those  who  present  laryngeal  or  gastric  crises. 

These  two  forms  of  crises  are  by  far  the  most  frequent.  But.  in 
addition,  we  have  intestinal  crises,  urethral  crises,  rectal  crises,  genital 
crises,  renal  crises,  cardiac  crises,  and  others,  in  wliich.  as  the  chief 
symptom,  violent  paroxysms  of  pain  occur,  that  pass  away  and  are 
found  not  to  be  connected  with  any  organic  change  of  the  seemingly 
diseased  pari.  The  true  meaning  of  these  pain  crises,  as  well  as  the 
distinction  from  the  visceral  affections  they  simulate,  is  detected  m  the 
absent  knee-jerk  and  in  the  other  symptoms  of  the  ataxic  malady. 

In  considering  the  diagnosis  of  locomotor  ataxia,  let  us  first 
examine  how  it  differs  from  general  paralysis  of  the  msane.  Both 
maladies  are  very  chronic  in  their  course,  and  in  both  there  is  loss, 
or  certainly  impairment,  of  muscular  co-ordination.  In  the  one  case, 
however,  it  exists  with  tremors,  with  thickness  of  speech,  vnih.  de- 
mentia, mth  peculiar  delusions,  with  exaggerated  knee-jerks.  Then, 
in  locomotor  ataxia,  the  hands  are  rarely  affected :  indeed,  should,  in 
process  of  time,  the  upper  extremities  share  in  the  disorder,  there  is 


1  Xewmark's  case,  Medical  News,  Jan.  26,  1895. 

2  Hutchinson,  Transact.  Royal  Medico-Chirurg.  Soc,  1879. 
'  Diseases  of  the  Xen-ous  System,  1882. 

*  Cathelinean,  Arch.  Gen.  de  Med.,  April,  1894. 


DISEASES  OF  THE  BEAIN  Als^D   SPINAL   CORD.  141 

in  them  often  rather  cutaneous  anaesthesia,  with  some  trembhng,  than 
an  obvious  failure  of  co-ordinating  power.  It  must  also  be  remem- 
bered that  the  two  diseases  sometimes  exist  in  combination. 

With  reference  to  the  distinction  of  progressive  locomotor  ataxia 
from  most  of  the  diseases  of  the  spinal  cord,  the  extreme  rarity  of 
muscular  spasm  in  ataxia  must  be  dwelt  on ;  from  spinal  paraplegia 
the  result  of  myelitis  it  differs  in  the  fact  that  the  muscles  act  with 
strength,  the  patient  can  flex  and  extend  Ms  legs  and  kick  vigorously, 
while  in  spinal  myelitis  the  affected  limbs  cannot  move,  though  the 
knee-jerk  may  be  excessive.  The  lightning  pains  are  not  entirely  to 
be  trusted  to  in  diagnosis,  for  they  may  happen  in  acute  myelitis  as 
well  as  in  spinal  pachymeningitis  and  in  disseminated  sclerosis.  The 
absence  of  the  knee-jerk  in  locomotor  ataxia  is  of  very  great  value. 
Its  presence,  in  addition  to  the  tremor,  the  nystagmus,  and  the  scan- 
ning speech,  distinguishes  disseminated  cerebrospinal  sclerosis.  But 
mixed  symptoms  may  exist  from  the  different  forms  of  sclerosis 
being  combined.  In  ataxic  paraplegia  we  have  both  disease  of  the 
posterior  and  lateral  columns  and  a  combination  of  the  symptoms  of 
spastic  paraplegia  and  of  locomotor  ataxia.  The  knee-jerk  is  exces- 
sive, ankle-clonus  is  present,  and  there  are  extensor  spasms  in  addi- 
tion to  Aveakness  and  to  the  incoordination ;  but  no  lightning  pains  or 
loss  of  light  reflex  attend  the  ataxia,  as  in  tabes. 

Putnam  and  Dana  have  described  cases  presenting  chroniG  sclerosis 
of  the  posterior  and  lateral  columns,  especially  of  the  pyramidal  and 
cerebellar  tracts,  which  are  very  puzzling.  Among  the  symptoms  are 
numbness  in  the  extremities,  progressive  loss  of  strength,  and  wasting. 
The  knee-jerks  are  at  first  exaggerated,  but  later  they  are  enfeebled  or 
lost,  and  paraplegia  develops.  The  lower  extremities  suffer  in  greater 
degree  than  the  upper.     Mental  symptoms  may  appear. 

There  is  a  chronic  degeneration  of  the  spinal  cord  having  its  chief 
seat  in  the  posterior  columns  and  the  lateral  pyramidal  tracts,  which 
mostly  develops  in  childhood.  It  is  often  hereditary,  usually  occurs 
in  families,  is  probably  congenital  in  origin,  and  has  as  its  chief  symp- 
tom ataxia.  This  disease  is  known  as  Friedreich's  ataxia,  and  also  as 
hereditary  ataxia,  and  is  of  very  long  duration.  The  disorder  of  co- 
ordination shows  first  in  the  lower  extremities,  and  advances  up- 
ward, at  last  affecting  the  organs  of  speech.  The  patellar  tendon 
reflex  is  generally  abolished ;  nystagmus  [and  vertigo  are  frequent ; 
while  in  the  later  stages  spasms  and  contractions  of  muscles,  curva- 
ture of  the  spine,  want  of  control  in  keeping  any  part  of  the  body 
quiet,  and  palsies,  are  not  uncommon.  Unlike  what  takes  place  in 
locomotor  ataxia,  we  note  no  disorder  of  cutaneous   sensibility,  no 


142  MEDICAL   DIAGNOSIS. 

lancinating  pains,  no  atrophy  of  the  optic  nerves,  no  Argyll-Robertson 
pupil,  no  trophic  lesions,  no  visceral  disturbances.^ 

From  diphtheritic  ,paralysis  we  distinguish  tabes  by  the  history  of 
the  malady,  the  absence  of  pain,  and  by  the  paralysis  of  accommoda- 
tion and  of  the  palate  that  precedes  the  muscular  weakness.  Loss 
of  knee-jerk  exists  in  both,  and  occasionally  incoordination  is  met 
with  in  the  former.  In  multiple  neuritis  this,  too,  may  happen ;  but 
the  marked  muscular  and  nerve  tenderness,  the  changed  electric  re- 
actions, the  normal  pupils,  the  absence  of  the  lightning  pains,  the 
more  decided  loss  of  muscular  power,  and,  usually,  the  evidence  of 
alcoholism,  tell  the  true  meaning. 

A  diminution  or  loss  of  the  muscular  sense — that  guiding  sense  by 
which  we  judge  of  the  position  of  the  limbs,  by  which  we  are  con- 
scious of  their  movements — occasions  difficulty  in  diagnosis,  since  in 
locomotor  ataxia  the  muscular  sense  may  be  also  deficient.  On  the 
other  hand,  in  the  former  morbid  state  the  motion  may  be  somewhat 
impaired,  for,  as  in  tabes,  the  feet  may  feel  numb  in  standing  and  in 
walking,  and  the  patient  be  unable  to  walk  in  the  dark.  But  there  is 
this  difference :  where  merely  the  muscular  sense  is  affected,  he  can 
walk  and  perform  all  •movements,  even  those  of  a  complex  nature, 
without  vacillation,  so  long  as  his  eye  is  fixed  on  them  and  super- 
intends and  gives  them  direction ;  while  in  tabes  the  derangement  of 
muscular  co-ordination  renders,  even  with  the  aid  of  sight,  the  move- 
ments uncertain  and  irregular.  Then  cutaneous  anaesthesia  is  apt  to 
coexist  with  this  malady.  The  treatment,  too,  will  throw  light  on  a 
doubtful  case :  the  local  use  of  electricity  will  usually  cure  the  loss  of 
muscular  sense,  as  seen  principally  in  hysterical  paralysis  ;  it  has  no 
curative  effect  in  ataxia. 

Irrespective  of  the  affection  of  muscular  sense,  the  greatest  simi- 
larity to  locomotor  ataxia  I  have  seen  has  been  in  several  cases  of 
hysteria;  one  in  particular,  in  a  very  angemic  woman,  resembled  it 
closely ;  and  it  may  be  a  question  whether  the  nutrition  of  the  parts 
affected  in  ataxia  was  not  disordered,  and  the  nervous  structure 
functionally  disturbed.  I  desire  particularly  to  call  attention  to  these 
cases,  which  can  be  distinguished  by  their  history,  the  usual  coexist- 
ence of  ansemia,  and  the  absence  of  severe  darting  pains.  Yet  pains 
may  also  happen  in  the  hysterical  complaint,  as  in  a  case  I  saw  with 
Dr.  Webb;^  but  this  is   uncommon.     Moreover,  the  apparent  want 

^  For  an  admirable  analysis  of  cases,  see  Crozer  Griffith's  paper  in  the 
Transactions  of  the  College  of  Physicians  of  Philadelphia,  1888.  Sanger  Brown, 
Chicago  Medical  Recorder,  Feb.  1892,  publishes  a  very  striking  family  tree. 

2  Amer.  Journ.  Med.  Sci.,  Jan.  1876. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  I43 

of  muscular  co-ordination  is  more  irregular  in  its  manifestations,  the 
knee-jerk  is  not  lost, — though  rigidity  of  the  limbs  may  make  this 
very  difficult  to  ascertain, — and  the  cases  recover.  So,  I  think,  may 
cases  of  locomotor  ataxia  due  to  special  causes.  For  I  have  seen 
cases  in  si/philitic  patients,  typical  in  everything  except  perhaps  the 
severity  of  the  neuralgic  pain,  essentially  typical  in  the  muscular 
phenomena  and  in  the  inability  to  walk  with  closed  eyes,  in  which  a 
gradual  and  nearly  complete  recovery  took  place.  Here  the  lesion 
was  probably  removed  or  greatly  influenced  by  the  anti-syphilitic 
treatment,  and  a  true  or  extensive  sclerotic  degeneration  of  the  affected 
parts  did  not  take  place. 

Diseases  of  the  Cerebellum. — Diseases  of  the  cerebellum  pro- 
duce many  of  the  phenomena  regarded  as  peculiar  to  locomotor 
ataxia.  But  the  gait  of  the  patient  is  that  of  a  drunken  man  :  when 
attempting  to  walk,  he  leans  to  one  side,  moves  in  arcs  of  a  circle,  or 
describes  zigzags  ;  and  when  standing  erect,  his  body  swings  back- 
ward and  forward,  or  from  side  to  side,  though  his  feet  remain 
quietly  fixed  on  the  ground.  In  ataxia,  on  the  other  hand,  the  mus- 
cular contractions  in  the  erect  position  or  during  attempts  at  walking 
are  strong  and  sudden,  more  like  spasms,  yet  not  spasmodic,  and  have 
as  their  object  to  keep  the  body  in  the  line  of  gravity ;  and  the  walk, 
though  accomplished  with  difficulty,  is  straight,  not  reeling ;  the 
affected  person,  too,  while  he  is  walking,  does  not  take  his  eyes  off 
the  ground  or  off  his  feet,  from  fear  of  falling ;  but  he  is  not  giddy. 
The  peculiar  gait  of  cerebellar  affections  is  particularly  found  when 
the  middle  lobe  is  involved.  Disease  spreading  from  the  cerebellum 
gives  rise  to  hypoglossal,  facial,  and  other  local  palsies.  In  diseases 
of  the  cerebellum  we  find  vertiginous  sensations,  especially  during 
attempts  at  locomotion,  which  may  be  easier  and  straighter  with  the 
eyes  shut  than  with  them  open  ;  vomiting,  particularly  at  the  onset  of 
the  complaint,  aggravated  or  brought  on  by  the  erect  posture  ;  nystagv 
mus  ;  severe  headache,  occipital  or  frontal,  when  the  head  is  bent ; 
defective  vision,  but  with  normal  pupillary  reaction,  or  double  vision, 
though  the  eye-disturbances  may  or  may  not  be  associated  with 
choked  disk  or  optic  neuritis ;  no  diminution  either  of  power  of 
motion  or  of  sensibility,  unless  from  pressure  on  adjacent  parts ;  and  ■ 
in  some  instances  rotary  movements  and  hemiplegia.  Rotary  move- 
ments are  regarded  as  a  special  proof  of  affection  of  the  cerebellar 
peduncles.  The  knee-jerks  are  sometimes  wanting,  sometimes  exag- 
gerated ;  there  are  no  leg-pains.  When  the  disease  is  localized  in 
one  hemisphere  of  the  cerebellum,  it  may  cause  no  symptoms. 


144  MEDICAL  DIAGNOSIS. 

Tremor. 

Any  involuntary  agitation  of  the  body,  or  of  part  of  it,  without 
marked  muscular  contraction  or  impediment  to  voluntary  movement, 
is  called  tremor.  The  trembling  depends  upon  a  weakening  of  the 
muscular  and  nervous  systems.  It  is  common  in  old  age,  in  conva- 
lescence from  debilitating  diseases,  in  hysteria,  in  neurasthenia,  and 
during  chills.  We  also  find  it  in  workers  in  mercury  or  in  lead  or  in 
arsenic ;  in  those  who  abuse  alcoholic  stimulants  or  coffee  or  tobacco, 
or  who  are  addicted  to  the  use  of  opium  ;  and  in  cases  of  exophthal- 
mic goitre.  It  may  be  connected  with  an  organic  disease  of  the  ner- 
vous centres,  as  in  cerebro-spinal  sclerosis  ;  and  it  constitutes  the 
main  symptom  of  the  disorder  known  as  paralysis  agitans. 

Tremor  is  easily  recognized.  Yet  it  may  be  confounded  with  mus- 
cular twitchings.  But  it  differs  from  these  spasmodic  movements  by 
being  more  incessant,  and  unconnected  with  decided  muscular  con- 
tractions. In  nervous,  susceptible  persons  laboring  under  an  acute 
attack  of  disease,  it  is  at  times  combined  with  great  restlessness,  and 
is  apt  to  be  mistaken  for  a  convulsive  state.  Here  again  it  may  be 
distinguished  by  the  absence  of  muscular  contractions,  and  by  the 
unintermitting  irregular  motions.  Tremor,  which  is  produced  or  at 
least  exaggerated  by  voluntary  motion,  is  known  as  intention  tremor. 

Paralysis  Agitans. — Tremor  is  the  chief  symptom  of  paralysis 
agitans  or  shaking  palsy.  The  trembling  consists  of  fine  small  move- 
ments, is  combined  with  muscular  weakness,  or  rather  with  slowness 
of  muscular  action,  and,  while  increased  by  exertion  and  mental 
excitement,  it  persists  during  rest,  though  it  ceases  during  sleep.  It 
usually  follows  continuous  mental  strain,  emotional  shock,  prolonged 
exposure  to  damp,  or  some  depressing  acute  affection  in  elderly  per- 
sons ;  it  may  be  due  to  trauma  or  to  excessive  use  of  a  member ;  it 
comes  on  slowly  and  progresses  slowly;  it  ordinarily  begins  in  the 
hand  or  foot  and  gradually  becomes  general.  The  disease  lasts  for 
years:  as  it  advances,  the  patient  loses  his  equilibrium  in  walking, 
leans  forward  or  walks  on  the  fore  part  of  the  foot,  and  is  rapidly 
propelled  forward,  but  he  may  be  propelled  to  one  or  the  other  side 
or  even  backward. 

The  trembling  takes  place  over  |the  entire  body,  and  sometimes 
involves  the  head.  It  is-  in  more  or  less  continuous  oscillations,  at 
first,  at  least  to  a  certain  extent,  controlled  by  the  will.  It  is  increased 
by  emotional  influences,  and  lessened  by  active  or  passive  movement. 
The  muscles  react  to  both  the  faradic  and  the  galvanic  current.  The 
expression  of  the  countenance  is  vacant  and  fixed ;  the  handwriting 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  145 

is  tremulous,  the  voice  piping,  monotonous,  the  speech  indistinct,  at 
times  hurried ;  the  muscles  of  the  extremities  become  rigid,  espe- 
cially the  flexors,  producing  deformities  like  those  of  rheumatoid 
arthritis.  Sensation  is  unaffected,  though  there  are  abnormal  subjec- 
tive sensations  and  great  restlessness.  Complaints  are  made  of 
cramps,  of  muscular  stiffness,  especiahy  in  the  extremities,  and  of  a 
sense  of  excessive  heat,  associated,  indeed,  with  increased  temperature 
of  the  surface  and  sweating.  There  are  no  cerebral  symptoms  ;  yet 
hypochondriasis  and  loss  of  intellectual  power  occur  as  the  disease 
progresses.  The  hands  are  apt  to  assume  a  position  as  in  writing. 
The  knee-jerk  is  normal ;  it  may  be  increased.  In  exceptional  instances 
tremors  are  absent.  There  is  growing  belief  that  paralysis  agitans  is 
dependent  upon  nutritive  change  in  the  motor  cells  of  the  cortex  of 
the  brain. 

Under  the  name  of  simple  senile  paraplegia  Gowers  has  described 
an  affection  similar  to  paralysis  agitans  without  tremor,  in  which  this 
malady  manifests  itself  only  by  stiff  movement  and  by  ^weakness  of 
the  limbs,  face,  and  trunk.  In  simple  senile  paraplegia  these  signs 
show  themselves  especially  in  the  legs,  which  gradually  become 
weaker  and  weaker,  but  without  there  being  wasting  or  sensory  dis- 
turbance ;  there  are  also  slight  symptoms  in  the  arms  and  face.  The 
knee-jerk  is  normal,  and  foot-clonus  is  not  observed.  The  disease  is 
especially  met  with  after  fifty  years  of  age.  There  are  supposed  to 
be  degenerative  changes  in  the  leg-centres. 

Multiple  Cerebro-Spinal  Sclerosis. — Different  is  the  palsy 
dependent  upon  multiple  or  disseminated  cerebrospinal  sclerosis,  or 
Charcots  disease.  The  symptoms  of  this  vary  somewhat,  as  the 
nodules  of  hardened  tissue  affect  the  brain  or  the  cord  first.  We 
have  always  tremor  and  paralysis,  and  sometimes  sensory  changes. 
The  trembling  may  show  itself  from  the  start  in  the  tongue  or  the 
eyeball,  and  with  it  we  usually  find  headache,  vertigo,  failure  of  sight, 
nystagmus,  amblyopia,  impaired  hearing,  and  at  times  gastralgia  and 
vomiting.  The  want  of  power  manifests  itself  in  all  the  extremities, 
yet  the  lower  exhibit  the  palsy  most  plainly,  while  the  characteristic 
trembling  is  most  evident  in  the  arms ;  unlike  paralysis  agitans,  the 
paresis  or  paralysis  often  precedes  the  tremor.  Save  in  rare  instances, 
the  trembling,  the  most  perfect  example  of  intention  tremor,  is  not 
witnessed  except  when  the  muscles  are  put  into  motion  ;  stops,  there- 
fore, entirely  or  nearly  so  when  they  are  at  rest :  it  is  usually  tested 
by  letting  the  patient  pass  a  glass  of  water  to  his  mouth.  It  occurs 
in  decided  jerks,  and  markedly  affects  the  head,  when  this  is  moved 
at  all.     The  gait  is  uncertain  and  tottering,  and  attempts  at  walking 


146  MEDICAL  DIAGNOSIS. 

increase  the  tremor.  The  voice  is  weak,  the  speech  slow  and  scan- 
ning ;  there  is  mental  elifeeblement,  with  failure  of  memory.  Sensa- 
tion is  at  first  not  affected,  nor  are  the  sphincters  ;  but  we  may  have 
hypersesthesia,  or  anaesthesia,  or  parsesthesia,  and  girdle-pains.  ■  One 
or  more  cranial  nerves  may  be  involved  in  the  sclerotic  process,  with 
resulting  disturbance  of  function.  The  tendon  reflexes  are  generally 
exaggerated,  and  foot-clonus  is  not  uncommon.  A  peculiarity  pointed 
out  by  Charcot  is  that  the  pupils  move  under  light,  and  that  the  pa- 
pilla is  yellowish.  Towards  the  end  muscular  cramps  followed  by 
contractions,  and  disorders  of  deglutition  and  of  respiration,  happen, 
or  there  may  be  attacks  of  an  apoplectic  character.  It  is  in  very 
advanced  cases  only  that  the  electro-muscular  contractility  or  the 
galvanic  irritability  of  the  nerves  is  decidedly  diminished.  Multiple 
sclerosis  is  most  common  between  twenty-five  and  thirty-five,  and 
lasts  for  years.  One  of  its  striking  features  is  that  long  delusive 
periods  of  marked  improvement  occur. 

The  description  given  shows  the  dissimilarity  between  it  and 
paralysis  agitans.  The  most  difficult  diagnosis  is  as  regards  Fried- 
reich's ataxia,  when,  as  it  occasionally  does,  disseminated  sclerosis 
happens  in  the  young.  The  disturbance  of  co-ordination  in  the 
former  malady  and  the  common  loss  of  knee-jerk  are  the  most 
obvious  differences. 

There  is  a  form  of  disease  in  which  the  symptoms  appear  like 
those  of  disseminated  sclerosis,  and  are  yet  due  to  an  infectious  pro- 
cess, such  as  scarlet  fever,  measles,  variola,  typhoid  fever,  and  in- 
fluenza. The  tremor  aggravated  by  intention,  the  scanning  speech, 
the  drooping  lip,  the  dull  expression  of  face  and  general  air  of  stupidity, 
the  spastic  gait  with  exaggerated  deep  reflexes,  are  common  to  both. 
Nystagmus  has,  however,  not  been  observed  in  this  pseudo-disseminated 
sclerosis^  and  the  cases  recover.  They  are  in  their  general  character, 
except  in  the  special  symptoms  that  approximate  them  to  sclerosis, 
like  the  pseudo-ataxia  which  is  also  observed  after  various  acute  in- 
fectious diseases.^ 

Hysteria  may  present  symptoms  resembling  those  of  cerebro- 
spinal sclerosis,  but  marked  and  persistent  ankle-clonus  is  wanting, 
as  is  also  the  plantar-reflex,  while  anaesthesia  of  the  lower  extremi- 
ties is  more  likely  to  be  present.  In  hysteria,  difficulty  in  micturition 
is  usual ;  in  disseminated  or  insular  sclerosis  occur  increased  frequency 
of  micturition  and  finally  incontinence. 

^  See  Westphal's  paper  in  his  Archiv,  vol.  xiv.  p.  87  ;  also  cases  collected  by 
Dawson  Williams,  Med.  Chir.  Trans.,  vol.  Ixxvii.,  1894. 


DISEASES  OF  THE  BRAIN  AND   SPINAL   CORD.  147 

There  are  other,  though  far  less  common,  forms  of  tremor  con- 
nected with  organic  disease,  such  as  the  post-hemiplegic  tremor  and 
the  tremor  in  spasmodic  tabes.  In  both  the  history  of  the  case  and 
the  attending  muscular  disorder,  with  the  violent  but  rhythmical 
tremors  on  attempted  motion  in  the  latter  affection,  are  of  great 
significance.  As  an  organic  tremor,  too,  m.ay  be  classed  that  of  old 
age.  In  this  senile  tremor  the  trembling  is  most  probably  due  to 
degenerative  changes  in  the  motor  tract.  At  first  it  happens  only  on 
voluntary  movement,  stopping  during  repose  and  sleep,  though  ulti- 
mately it  continues  during  rest  as  well  as  during  motion.  It  begins 
in  the  hands,  but  extends  markedly  to  the  neck  and  head,  and  finally 
becomes  very  much  like  the  tremor  of  paralysis  agitans.  Dana,^ 
studying  this  and  other  forms  of  tremor  with  great  accuracy  by  means 
of  Dudgeon's  sphygmograph,  states  senile  tremor,  indeed,  to  be  the 
evidence  of  an  abortive  form  of  paralysis  agitans. 

Functional  Tremors. — There  is  a  group  of  tremors  in  which 
there  is  no  organic  cause,  or  at  least  the  cause  is  so  fine  as  to  elude 
detection.  Toxic  tremors  belong  to  this  group,  and  we  will  look  at 
their  characteristics. 

Alcoholic  tremor  occurs  only  on  movement.  It  is  irregular,  and  of 
considerable  range.  It  is  very  pronounced  in  the  arms,  face,  and 
tongue  ;  in  the  legs  it  generally  shows  itself  only  when  they  are  put 
in  action,  as  in  an  attempt  to  stand.  It  is  associated,  in  acute  cases 
especially,  with  great  restlessness,  and  muscular  twitchings  are  not 
uncommon.  The  trembling  is  usually  worse  in  the  morning.  Then, 
too,  in  its  diagnosis  we  lay  stress  on  the  habits  of  the  patient. 

Tobacco  tremor  is  a  fine  tremor  which  more  especially  happens  in 
the  hands.  It  is  sometimes  seen  in  the  tongue,  which  is  smooth  and 
shiny,  and  is  apt  to  be  combined  with  a  relaxed  skin,  an  irritable 
heart,  and  feebleness  of  sight. 

Lead  tremor  is  also  a  fine  tremor.  It  is  irregular  in  its  distribution, 
usually  seen  in  the  hands,  increased  by  motion,  and  not  limited.  It 
is  often  associated  with  beginning  weakness  of  the  extensor  muscles 
of  the  forearm,  with  a  blue  line  on  the  gums,  and  may  involve  the  lips 
and  tongue. 

In  arsenical  tremor  the  trembling  is  wide-spread.  There  is  also 
some  difficulty  in  co-ordination,  with  beginning  muscular  paralysis, 
darting  pains  in  the  arms  and  legs,  and  diminution  of  tactile  sensi- 
bility. 

Mercurial  tremor.^  another  variety  of  tremor,  usually  appears  first 

1  Medical  News,  Dec.  1892. 


148  MEDICAL  DIAGNOSIS. 

in  the  tongue  and  face,  and  later  extends  to  the  arms  and  legs.  It  is 
increased  by  emotion  and  effort,  and  is  recognized  by  observing  that 
the  trembling  and  the  incessant  movements  stop  when  the  shaking 
limb  is  supported.  Then  the  gradual  manner  in  which  the  disease 
appears,  its  occurrence  among  persons  whose  occupations  predispose 
them  to  the  absorption  of  mercury,  the  wakefulness,  the  disorder  of 
the  digestive  organs,  and  the  sponginess  of  the  gums,  form  a  group  of 
phenomena  very  characteristic. 

Asthenie  tremor,  such  as  follows  debilitating  disease,  is  fine,  is  in- 
duced by  voluntary  movement,  and  is  most  marked  after  exertion  or 
fatigue. 

Hysterical  tremor  may  be  fine  and  irregular,  or  coarse  and  rhyth- 
mical. It  is  usually  induced  by  emotion  and  movement,  although 
the  second  variety  may  occur  independently. 

The  tremor  that  commonly  attends  exophthalmic  goitre  may  be 
regular,  but  is  often  coarse  and  jerky,  and  occurs  only  on  movement. 

There  is  a  form  of  functional  tremor  which  is  found  to  be  uncon- 
nected with  any  obvious  cause  and  may  last  through  life.  This 
essential  tremor,  to  call  it  by  that  name,  comes  on  often  in  young 
persons  and  lasts  through  life.  It  is  generally  fine,  but  sometimes 
irregular  and  unequal,  and  is  apt  to  be  associated  with  other  hyster- 
ical manifestations ;  it  is  sometimes  very  severe,  as  in  the  case  re- 
corded by  Lloyd,^  in  which  marked  hysterical  anorexia  coexisted.  It 
shows  itself  most  markedly  in  the  hands,  is  made  worse  by  excite- 
ment and  by  attempts  at  motion,  and  to  a  great  extent,  but  not  en- 
tirely, ceases  during  rest.  It  is  not  associated  with  any  other  motor 
disturbance,  and  I  have  known  it  in  persons  of  high  intellectual  en- 
dowments. It  may  not  come  on  until  middle  ag'e,  is  not  dangerous, 
but  is  not  curable.  In  an  instance  that  came  under  my  observation 
the  father  and  the  son,  a  young  man,  both  had  it  at  the  same  time  to 
an  equal  degree.  Kindred  to  it  is  the  hereditary  tremor  described  by 
Dana,  which  also  is  a  fine  tremor,  that  does  not  interfere  with  co-ordi- 
nation, and  which  affects  especially  the  upper  extremities.  It  begins 
in  infancy  or  childhood  and  continues  during  a  lifetime,  without 
shortening  life.  It  is  often  brought  out  by  an  infectious  fever,  ceases 
during  sleep,  and  may  become  associated  with  slight  contractures  of 
the  fingers.^ 


1  Amer.  Journ.  Med.  Sci.,  Sept.  1893. 
Mbid.,  Oct.  1887. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  149 

Spasms — C  onvulsions . 

Both  these  terms  are  apphed  to  involuntary  muscular  contrac- 
tions, with,  perhaps,  this  difference  :  the  word  spasm  is  used  when 
we  wish  to  express  the  idea  of  less  extensive  muscular  derangement, 
and  especially  when  the  muscles  of  organic  life  are  believed  to  be  in- 
volved ;  and  convulsions,  when  the  disorder  affects  the  muscles  of 
the  whole  body,  or  at  least  many  muscles  at  once,  and  chiefly  those 
of  volition. 

Spasms  may  be  clonic  or  tonic.  In  donie  spasms  the  muscles  are 
agitated  by  successive  contractions  and  relaxations  of  their  fibres. 
In  to7iic  spasms  the  muscles  are  rigidly  set,  and  retain  for  a  time  their 
contraction,  in  spite  of  every  effort  on  our  part,  or  on  the  part  of  the 
patient,  to  relax  them.  The  most  marked  type  of  this  disorder  is  seen 
in  tetanus ;  the  most  perfect  illustration  of  clonic  spasms  is  furnished 
by  hysteria. 

Convulsions  may  be  accompanied  by  a  loss  of  consciousness,  and 
abolished  sensibility,  as  in  epilepsy ;  or  they  may  coexist  with  un- 
clouded thought  and  unaltered  sensibility,  as  in  tetanus.  What  their 
immediate  cause  is,  it  is  very  difficult  to  determine.  General  evidence 
favors  the  cortex  of  the  brain  or  the  medulla  as  being  the  centres  dis- 
turbed ;  but  the  irritation  need  not  be  direct,  it  may  be  reflected  to 
them.  Of  their  exciting  cause  we  may  say  that,  in  those  of  suscepti- 
ble nervous  organizations,  any  extrinsic  irritation,  such  as  teething  or 
disordered  digestion,  leads  to  a  fit.  Further  causes  are  diseases  of 
the  brain ;  sudden  interference  with  the  circulation ;  profuse  hemor- 
rhages ;  anaemia ;  contaminated  blood ;  the  toxic  influence  of  lead. 
Children  often  have  convulsions  as  the  precursors  of  febrile  diseases. 
Convulsions  have  further  been  observed  as  a  result  of  rupture  of  the 
stomach.^  In  point  of  diagnosis  it  is  of  great  importance  to  distin- 
guish whether  their  inroad  is  or  is  not  symptomatic  of  a  cerebral 
lesion.  If  there  have  been  a  previous  manifestation  of  a  brain  affec- 
tion, we  may  assume  the  convulsions  to  be  the  signal  of  cerebral  mis- 
chief. Practically  speaking,  when  convulsions  are  among  the  first 
signs  of  a  malady,  they  are  not  apt  to  depend  upon  a  disease  of  the 
brain ;  and  even  if  recognized  to  form  part  of  the  symptoms  of  a 
cerebral  lesion,  we  may  conclude  that  the  lesion  has  not  reached  its 
highest  degree  of  development,  but  is  still,  as  it  were,  irritative. 

Besides  separating  convulsions  or  spasms  in  conformity  with  their 
centric  or  their  eccentric  origin,  we  must  always  attempt  to  ascertain 

1  O'Farrell,  Lancet,  vol.  i.,  1894,  p.  1243. 


150  MEDICAL  DIAGNOSIS. 

the  particular  nature  of  the  cause.  If  centric,  is  it  congestion,  inflam- 
mation, a  tumor,  sclerosis,  or  other  lesion  of  the  brain  or  mem- 
branes ?  or  is  it  the  convulsion  due  to  influences  the  cognizance  of 
which  is  not  within  our  horizon  ?  If  eccentric,  is  it  owing  to  an  im- 
pure or  impoverished  blood,  to  retained  poisons,  to  ptomaines,  or  is 
it  peripheral  from  nerve  lesion  or  intestinal  or  other  visceral  irrita- 
tion ?  and  in  how  far  reflex  ?  To  solve  these  questions  is  often  very- 
difficult,  and  nothing  but  a  careful  analysis  of  all  the  phenomena  of 
the  case  enables  us  even  to  approximate  the  truth. 

Among  the  most  extraordinary  forms  of  spasm  connected  with 
increased  reflex  irritability  of  the  cord  is  the  so-called  saltatory  spasm, 
in  which  so  violent  a  spasm  of  the  legs  takes  place  when  the  patient's 
feet  touch  the  floor  that  he  is  thrown  into  the  air.  In  some  instances, 
as  in  one  described  by  Bamberger,  palpitation,  dyspnoea,  and  ine- 
quality of  the  pupils  also  existed.  Other  forms  of  tonic  or  clonic  spasm 
happen  from  reflex  irritation  of  certain  nerve-tracts,  and  these  func- 
tional spasms  produce  for  the  time  being  the  most  singular  contortions 
and  deformities. 

Rhythmic  movements  of  the  head,  associated  with  nystagmus,  are 
occasionally  observed  in  infants  and  young  children.  The  oscillation 
is  sometimes  horizontal,  sometimes  vertical,  sometimes  both.  Many 
of  these  children  are  rhachitic,  some  are  epileptic.  Occasionally 
there  is  an  antecedent  history  of  traumatism.  In  some  cases  the 
condition  is  connected  with  defective  light  in  the  crowded  dwellings 
of  the  poor,  necessitating  almost  constant  artificial  illumination.^ 

Friedreich  has  described  as  "  paramyoclonus  multiplex"  a  condi- 
tion of  clonic  spasm  often  recurring  in  paroxysms  and  involving  the 
arms  and  legs  and  face  and  neck.  The  movements  are  increased  by 
emotion,  and  may  be  controlled  by  voluntary  effort. 

Closely  associated  with  spasms  are  other  kinds  of  irregular  mus- 
cular movements,  such  as  cramps, — a  contraction  of  short  duration 
of  one  or  of  several  muscles,  occurring  in  paroxysms  and  attended 
with  severe  pain  ;  rigidity, — a  more  lasting  tonic  contraction  of  the 
muscles  ;  and  the  jerking  movements  of  chorea.  Now,  some  of  these, 
especially  localized  spasm  and  even  rigidity,  have  a  strong  connec- 
tion with  the  seat  and  character  of  the  lesion.  Thus,  broadly  speak- 
ing, if  we  have  spasm,  perhaps  alternating  with  chorea-like  move- 
ments, confined  to  one  arm,  one  leg,  one  group  of  muscles,  we  may 
infer  an  irritative  lesion '  in  the  cortical  motor  area,  affecting  in  this 
monospasm  the  centre  presiding  over  the  motion  of  the  disordered 

1  Lewi,  Medical  News,  Nov.  10,  1894. 


DISEASES   OF  THE  BRAIN  AND   SPINAL   CORD.  151 

parts.  Early  rigidity  in  the  muscles,  especially  after  hemorrhage,  is 
apt  to  be  associated  with  increased  faradic  and  reflex  excitability, 
but  the  contracted  muscles  become  relaxed  during  sleep ;  in  late 
rigidity  the  contraction  or  "  contracture"  is  increased  by  movements, 
whether  voluntary  or  passive. 

DERANGED   NUTRITION   AND    SECRETION. 

Derangements  of  nutrition  and  secretion  are  especially  manifest 
in  paralyzed  limbs  or  after  nerve-wounds.  But  these  obvious  altera- 
tions need  here  only  be  referred  to  ;  it  is  the  intention  to  speak  rather 
of  the  less  palpable  phenomena,  the  trophoneuroses,  in  which,  at  first 
sight,  the  nervous  system  is  not  so  distinctly  concerned.  For  in- 
stance, there  is  to  be  noted  the  rapid  development  of  blisters  and 
bedsores  in  connection  with  marked  cerebral  and  spinal  lesions  ;  the 
skin  may  become  the  seat  of  diverse  eruptions,  undergo  modifica- 
tions of  color  and  structure,  the  secretions  may  be  augmented  or  di- 
minished, the  muscles  and  joints  show  textural  changes,  swellings 
may  happen  affecting  various  portions  of  the  body,  either  external  or 
internal, — yet  all  be  due  to  disturbed  nervous  infiuence,  and  the  real 
disorder  be  in  parts  very  different  from  where  it  appears.  Then  we 
find  the  trophic  symptoms  of  atrophy  of  the  muscles  in  acute  polio- 
myelitis and  in  Friedreich's  ataxia,  in  the  latter  afl'ection  often  associ- 
ated with  blueness  and  coldness  of  the  feet  from  vasomotor  change. 

To  particularize  with  reference  to  a  few  of  the  derangements 
mentioned.  There  is  the  affection  described  as  herpes  zoster^  in  which 
the  vesicles  encircling  half  the  circumference  of  the  trunk  are  not  a 
primary  skin  disorder,  but  the  local  expression  of  irritation  of  a 
nerve, — most  generally  of  a  dorso-intercostal  neuralgia.  Then  we 
encounter  instances  of  large  vesicles  or  bullge  accompanying  other 
neuralgias,  as  of  the  sciatic ;  and  attacks  of  erythema  having  their 
origin  in  facial  neuralgia.  Furthermore,  various  kinds  of  spots  and 
blotches,  and  thickenings  of  the  periosteum  and  of  the  skin,  have 
been  noticed  after  this  and  other  forms  of  neuralgia ;  and  we  have 
eruptions  of  zoster  in  chronic  myelitis  and  rashes  limited  to  the  limbs 
afi'ected  with  pain  in  locomotor  ataxia ;  and  eczema  of  nervous  origin 
produced  by  reflex  irritation  in  disorders  of  the  urinary  organs  ;  ^  and 
ichthyosis  of  the  lower  extremities  in  chronic  spinal  diseases. 

Oftentimes,  too,  these  morbid  appearances  on  the  skin  are  com- 
bined with  evidences  of  altered  secretion.  Thus,  in  a  case  related  by 
Parrot,^  in  addition  to  the  neuralgic  paroxysms  attended  with  san- 

1  Ord,  St.  Thomas's  Hospital  Reports,  vol.  vii.,  1876. 

^  Gaz.  Hebdom.,  1859  ;  Handfield  Jones  on  NeiTOUS  Disorders. 


152  MEDICAL  DIAGNOSIS.    - 

guineous  exudations  at  the  painful  parts,  there  occurred,  at  times, 
bloody  sweating  of  the  knees,  thighs,  hands,  and  face.  Lachrymation 
was  noticed  in  nearly  half  the  cases  of  trigeminal  neuralgia  analyzed 
by  Notta ;  ^  and  one-sided  furring  of  the  tongue  is  a  not  uncommon 
phenomenon  in  this  complaint.  Associated  with  these  evidences  of 
altered  secretion  may  be  signs  of  altered  nutrition,  such  as  iritis,  cor- 
neal clouding,  and  inflammation  of  the  fascia  or  of  the  periosteum 
in  contact  with  the  aching  nerve.  Let  us  add  that  these  manifesta- 
tions of  perverted  nutrition  are  not  confined  to  neuralgic  disorders. 
Trophic  changes  occur  also  in  diseases  of  the  central  nervous  system. 
Thus,  inflammatory  afl'ections  of  the  joints  have  been  observed  to 
follow  cerebral  hemorrhages,  and  various  spinal  maladies,  particularly 
acute  myelitis  ;  local  dryness  of  the  skin  occurs  in  unilateral  atrophy 
of  the  face,  ^nd  in  some  cases  of  syringomyelia ;  a  form  of  joint- 
mischief,  of  hydrarthrosis,  has  been  specially  described  in  locomotor 
ataxia  by  Charcot;  affections  of  the  joints  have  also  been  observed 
in  syringomyelia ;  and  the  perforating  ulcer  of  the  foot  has  been 
found  by  Ball^  and  Fayard^  to  be  often  connected  with  locomotor 
ataxia.  Perforating  ulcer  of  the  foot  has,  however,  also  been  noticed 
in  Morvan's  disease. 

(Edema  happens  also  as  a  vasomotor  change.  Weir  Mitchell  ^ 
points  out  swelling  of  the  limbs  in  menstrual  periods.  Furthermore, 
we  find  local  oedematous  swellings  occurring  in  various  parts  of  the 
body  associated  with  intestinal  disturbance,  sometimes  periodically 
and  with  an  hereditary  tendency,  and  this  angio-neurotic  oedema  has 
been  reported  by  Osier  ^  as  afi'ecting  members  of  a  family  for  five 
generations. 

Among  the  phenomena  of  altered  secretion  connected  with  ner- 
vous affections,  one  of  the  most  striking  is  excessive  sweating.  In  lesions 
of  the  cervical  sympathetic  on  one  side,  we  may  have  strictly  uni- 
lateral sweating  of  the  face  and  neck,  the  other  side  remaining  per- 
fectly dry ;  ^  and  greater  vascularity  and  increased  temperature  are 
concomitants.  In  lesions  of  the  abdominal  ganglia,  profuse  sweating 
also  happens,  and  is  apt  to  be  combined  with  impeded  secretion  from 
the  mucous  coats  of  the  bowels,  as  we  at  times  find  in  instances  of 
abdominal  aneurism.     Not  that  excessive  sweating,  whether  localized 

1  Arch.  Gen.  de  Med.,  1854. 

^  Trans,  of  Internat.  .Med.  Congress,  vol.  ii.,  London,  1881. 

3  These  de  Paris,  1881. 

*  Amer.  Journ.  Med.  Sci.,  July,  1884. 

5  Ibid.,  April,  1888. 

^  As  in  the  case  recorded  by  W.  Ogle,  Med.-Chir.  Trans.,  vol.  lii. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  I53 

or  general,  is  always  linked  to  an  affection  of  the  great  sympathetic 
ganglia.  We  find  local  sweatings  limited  to  the  hands  and  feet  with- 
out any  signs  of  other  disorder.  And  general  sweatings,  irrespective 
of  those  of  colliquative  character  attending  phthisis,  or  of  those  of 
malarial  diseases,  happen  after  low  fevers,  in  influenza,  in  inactive 
states  of  the  liver,  and  in  some  persons  go  on  for  years  without 
obvious  cause.  It  may  be  that  in  these  cases  the  sympathetic  system 
is  really  at  fault,  at  least  in  so  far  that  there  is  a  reflex  derangement 
of  the  vasomotor  nerves,  and  of  course,  then,  of  the  subcutaneous 
blood-vessels  and  of  the  glands  they  supply. 

But  these  are  not  questions  which  we  can  here  consider.  Indeed, 
the  ivhy  and  the  hoiv  of  all  these  changes  of  secretion  and  nutrition 
attending  nervous  affections  are  still  very  uncertain. 

To  return  to  the  clinical  phenomena.  Besides  the  external  mani- 
festations of  altered  secretion  and  nutrition,  there  are  certain  changes 
in  internal  organs,  the  expression  of  nervous  derangement.  There  is, 
for  instance,  exophthalmic  goitre ;  the  pneumonia  that  results  from 
injury  to  the  vagus  ;  the  ophthalmia,  which  may  even  pass  on  to  per- 
foration of  the  cornea,  that  happens  after  paralysis  of  the  trigeminus  ; 
the  kidney  disease  which  follows  chronic  spinal  affections. 

From  the  preceding  pages  it  will  have  become  apparent  how  many 
of  the  nervous  complaints  are  functional,  or  are  at  least  of  necessity 
so  regarded,  though  science  is  steadily  narrowing  their  number.  In 
consequence  of  the  uncertainty  respecting  the  functional  affections, 
doubt  is  thrown  over  any  anatomical  or  pathological  classification  of 
nervous  diseases.  I  subjoin  a  table  of  the  main  affections,  arranged 
according  to  their  supposed  sites.  In  several  of  the  disorders  re- 
garded as  functional  modern  research  has  indicated  the  probable 
organic  cause.  But  from  the  point  of  view  of  the  physician  it  would 
be  premature  to  hold  to  a  fixed  lesion,  and  I  contend  rather  for  the 
classification  being  useful  clinically  than  unimpeachable  pathologically. 
Nor  will  it  be  adhered  to  in  the  description  of  nervous  affections, 
which  will  be  traced  according  to  divisions  formed  by  groups  of  symp- 
toms and  not  in  obedience  to  a  pathological  classification. 

TABLE   OF   THE   AFFECTIONS   OF   THE   BRAIN   AND   SPINAL   CORD. 


Cerebral 


Organic . 


Hyperaemia. 
Anaemia. 

Meningitis  in  its  various  forms. 
Hydroceplialus. 
Abscess. 
Softening. 
10 


154 


MEDICAL   DIAGNOSIS. 


TABLE   OF   THE   AFFECTIONS 


Cerebral 


Organic . 


Functional . 


,Cerebro-Spinal 


Organic . 


Functional . 


Spinal 


Organic . 


Functional . 


OF   THE   BRAIN   AND   SPINAL   CORD.— 

Continued. 
Sclerosis. 

Hemorrhage  (Apoplexy). 
Thrombosis. 
Embolism. 
Tumors,  etc. 
Aneurism. 

Glosso-labio-laryngeal  paralysis. 
Syphilitic  affections. 

Delirium. 
Insanity  (?). 
Hypochondriasis. 
Headache. 
Trance. 

Cerebro-spinal  meningitis. 

Disseminated  cerebro-spinal  sclerosis. 

Paralysis  agitans. 

Simple  senile  paraplegia. 

Hydrophobia. 

Tetanus. 

Occupation-neuroses. 

Epilepsy. 

Catalepsy. 

Ecstasy. 

Chorea. 

Hysteria. 

Neurasthenia. 

Hyperaemia. 

Anaemia. 

Spinal  meningitis. 

Myelitis  in  various  forms. 

Softening. 

Atrophy. 

Sclerosis. 

Locomotor  ataxia. 

Spastic  paraplegia. 

Hereditary  ataxia. 

Ataxic  paraplegia. 

Spinal  apoplexy. 

Tumors,  etc. 

Syringomyelia. 

Syphilitic  affections. 

Progressive  muscular  atrophy. 

Spinal  irritation. 

Spinal  exhaustion. 

Tremor. 

Reflex  spasms  due  to  irritation  of  the  cord. 

Acute  ascending  paralysis. 

Myotonia. 


DISEASES  OF  THE  BEAIN  AND   SPINAL   CORD.  155 

Acute  Affections  of  which  Delirium  is  a  Prominent  Symptom. 

This  clinical  group  embraces  the  different  forms  of  meningeal  in- 
flammation, delirium  tremens,  and  acute  mania. 

Acute  Meningitis. — By  this  term  is  understood  an  inflammation 
of  the  membranes  of  the  brain,  especially  of  the  arachnoid  and  of  the 
pia  mater,  or  acute  leptomeningitis.  The  dura  mater  is  far  less  fre- 
quently attacked ;  very  rarely,  unless  the  morbid  action  be  of  syphi- 
litic origin,  or  have  extended  from  the  bones  of  the  cranium,  or 
resulted  from  an  injury. 

The  disease  generally  presents  two  well-marked  stages.  The 
first,  or  the  stage  of  excitement,  is  characterized  by  intense  headache, 
great  restlessness,  vomiting,  a  hard,  frequent  pulse,  slow  in  propor- 
tion to  the  temperature,  injected  eye,  often  with  a  contracted  pupil, 
strabismus,  an  increased  sensibility  to  light  and  sound,  obstinate  con- 
stipation, irregular  respiration,  stiffness  of  the  muscles  of  the  neck, 
and  soon  by  active  delirium,  and  by  convulsions.  The  temperature 
rarely  exceeds  103°  F.  In  the  second  stage  the  extremities  are  cold, 
the  pupils  dilated,  the  pulse  is  feeble  and  slower,  and  intermitting,  or 
becomes  extremely  rapid  and  thread-like  ;  involuntary  passages  occur  ; 
there  is  utter  loss  of  mind  and  of  sensibility, — in  one  word,  coma  or 
collapse.  In  this  stage  the  temperature  may  fall  below  the  normal, 
or  may  reach  106°.  Not  every  case,  however,  has  all  these  symp- 
toms, or  goes  at  once  from  the  stage  of  excitement  to  that  of  collapse. 
There  may  be  a  well-defined  period  of  transition,  during  which 
drowsiness  appears.  Again,  the  disease  may  be  arrested  before  the 
signs  of  prostration  are  evident. 

The  attack  may  be  preceded  by  sick  stomach,  buzzing  in  the  ears, 
and  vertigo,  or  it  may  set  in  with  severe  pain  fixed  to  the  forehead 
and  increased  by  movement.  In  some  cases  it  begins  with  delirium 
or  convulsions.  On  the  other  hand,  these  signs  may  be  absent.' 
Among  the  symptoms  of  the  affection,  even  in  the  earliest  stages,  a 
persistent  pain  attacking  one  or  both  knees,  violent,  intensified  on 
motion,  unrelieved  by  local  means,  and  connected  neither  with  swell- 
ing nor  with  any  other  change  in  the  form  or  appearance  of  the  joint, 
has  been  particularly  noticed.^  Another  sign,  as  of  every  form  of 
meningitis,  including  the  epidemic  cerebro-spinal,  is  the  so-called 
Kernig's  sign, — an  inability  to  extend  the  leg  when  the  thigh  is  flexed 
at  a  right  angle  with  the  body. 

^  In  a  paper  by  Church,  in  St.  Bartholomew's  Hospital  Reports,  vol.  iv.,  several 
cases  without  delirium  are  narrated. 

^  Lund,  quoted  in  Arner.  Journ.  Med.  Sci.,  Oct.  1864. 


156  MEDICAL  DIAGNOSIS. 

The  malady  may  pass  rapidly  through  its  stages,  so  rapidly  that 
their  distinctive  features  become  confused  and  blended.  Generally  it 
does  not  last  less,  or  much  more,  than  a  week.  There  is  marked 
emaciation  attending  it. 

Acute  meningitis  is  brought  on  by  alcoholism,  by  exposure,  by 
depressing  cares,  by  intense  application  to  study,  by  a  blow  or  fall 
upon  the  head,  by  disease  of  adjacent  structures,  or  by  syphilis  ;  or  it 
may  occur  in  the  course  of  chronic  nephritis,  of  the  wasting  diseases 
of  children,  or  of  infectious  processes,  such  as  measles,  scarlatina, 
smallpox,  typhoid  fever,  and  pyaemia,  though  it  is  rare  under  all 
these  circumstances  ;  finally,  it  may  be  due  to  pneumonia  or  to  inso- 
lation. Bacteriologically  it  is  chiefly  owing  to  the  meningococcus 
or  to  the  pneumococcus  meningitis,  and  this  not  only  in  connection 
with  pneumonia,  but  as  a  separate  malady.  Meningitis  sometimes 
affects  mainly,  or  wholly,  the  coverings  of  the  convex  portion  of 
the  brain ;  at  other  times  the  inflammation  is  limited  to  the  base. 
Meningitis  of  the  convexity  is  not  infrequently  purulent,  and,  if  puru- 
lent, temperatures  of  104°  to  105°  are  usual.  It  generally  comes  on 
suddenly,  and  is  found  to  be  connected  with  disease  of  the  bones  of 
the  skull,  with  ear-disease,  or  to  follow  exposure  to  the  rays  of  the 
sun.  Severe  headache,  intense  delirium,  hypersesthesia,  spasms  in 
the  facial  muscles  of  one  side  and  in  one  or  both  arms,,  and  hemi- 
plegic  weakness  are  among  the  most  marked  symptoms.  According 
to  Duchatelet,^  meningitis  of  the  base  may  be  discriminated  by  remis- 
sions in  the  delirium,  and  by  the  coexistence  of  spasmodic  symptoms 
with  profound  and  early  coma.  In  some  cases  acute  muscular  pains 
with  defective  motor  power,  a  clear  mind  until  late  in  the  disorder,  a 
temperature  of  105°,  have  been  specially  noticed.^  Moreover,  the 
longer  duration  of  the  malady,  the  delirium  of  varying  intensity  and 
later  appearance,  the  intervals  of  clearness,  and  the  late  and  incom- 
plete palsies,  are  regarded  as  significant  of  this  simple  basilar  menin- 
gitis.^ Then  persistent  vomiting,  paralysis  of  cranial  nerves,  marked 
rigidity  of  the  neck,  and  early  optic  neuritis  point  to  the  base ;  optic 
neuritis  is  indeed  rare  in  meningitis  or  meningo-encephalitis  of  the 
convexity.  Yet  there  is  no  certainty  in  the  diagnosis.  Nor  can  we 
be  sure  of  the  membrane  chiefly  involved  in  the  meningeal  inflam- 
mation. Inflammation  of  the  dura  mater,  or  pachymeningitis,  has  the 
least  severe  and  striking  symptoms.     It  is  most  commonly  noticed  as 

^  Inflammation  de  rArachnoide,  p.  230. 

^  Dowse,  Medical  Times  and  Gazette,  Feb.  1S74. 

•'•  Husruenin,  in  Ziemssen's  Cydopsdia. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  157 

due  to  extension  from  caries  of  the  bone,  to  injuries  of  the  head,  to 
syphilis,  or  to  sunstroke. 

A  form  of  inflammation  of  the  cerebral  meninges  characterized 
by  extravasation  of  blood  between  the  dura  mater  and  the  pia-arach- 
noid  is  known  as  hemot^rhagic  pachymeningitis.  It  has  been  observed 
most  commonly  in  the  chronic  insane,  and  in  cases  of  chronic  alcohol- 
ism. Among  the  symptoms  to  which  this  condition  gives  rise  are 
apoplectiform  seizures,  headache,  somnolence  or  coma,  muscular 
weakness,  nystagmus,  smallness  of  the  pupil,  optic  neuritis,  headache, 
and  vomiting. 

Acute  meningitis  is  not  always  easy  of  diagnosis.  Leaving  out  for 
the  present  the  other  disorders  belonging  to  the  same  group,  such  as 
acute  mania  and  delirium  tremens,  it  may  be  confounded  with 

Cerebritis  ; 

Acute  Softening  ; 

Intracranial  Tumor  ; 

Ear  Disease  ; 

Head  Symptoms  of  Continued  Fevers  ; 

Head  Symptoms  of  Acute  Rheumatism  : 

Head  Symptoms  of  Acute  Ulcerative  Endocarditis  ; 

Head  Symptoms  of  Pneumonia  ;  of  Pericarditis. 

Cerebritis. — There  is  little  appreciable  difference  between  acute 
inflammation  of  the  brain-tissue  and  inflammation  of  the  meninges. 
In  truth,  what  we  commonly  call  meningitis  is  not  infrequently  also 
cerebritis  ;  since  the  diseased  process  extends  readily  from  the  tunics 
of  the  brain  to  the  adjacent  cerebral  substance.  We  note  acute 
cerebritis  generally  as  the  result  of  an  injury  to  the  head,  of  contigu- 
ous inflammation,  of  ear-disease,  of  septic  influence,  or  of  acute 
infective  disease.  We  may  suspect  the  brain-structure  to  have  become 
involved  if  the  sense  of  vision  or  of  hearing  be  suddenly  perverted : 
if  the  convulsions,  the  agitation  of  the  limbs,  and  the  tremors  be  very 
marked ;  if  they  occur  chiefly  upon  one  side  ;  and  if  palsy  of  the 
limbs  or  face  rapidly  appears.  The  paralysis  is  generally  hemiplegic. 
Where  the  palsies  are  limited,  or  the  spasms  or  irregular  choreic 
movements  strictly  unilateral,  we  may  infer  that  the  disease  is  limited. 
that  we  are  dealing  with  an  acute  focal  enceplialitis.  Where  the  brain 
structure  is  extensively  involved,-  diffuse  encephalitis^  there  is  long- 
continued  torpor  of  mind  and  body,  and,  in  their  valuable  analysis 
of  cases,  Kneass  and  Brown  ^  look  upon  this  state  of  vacuity  as  of 
decided  diagnostic  value.     The  disease  occurs  especially  in  the  young. 

1  Brain,  vol.  xvi.,  1893. 


158  MEDICAL  DIAGNOSIS. 

Acute  Softening. — The  form  of  acute  softening  which  simulates 
meningitis  is  that  associated  with  delirium.  Acute  softening  is  almost 
always  the  result  of  arterial  occlusion  from  embolism  or  thrombosis, 
or  of  venous  thrombosis ;  arterial  thrombosis  is  by  far  the  most 
common  cause.  The  existence  of  disease  of  the  heart  or  of  the 
blood-vessels,  or  of  contracted  kidney,  gives  us  for  the  most  part  the 
clue  to  the  case.  The  palsied  side  has  often  a  decidedly  higher  tem- 
perature than  the  other  side.  The  general  temperature  is  that  of 
fever,  and  may  be  high,  104°  or  more.  In  the  cases  of  acute  soften- 
ing in  very  old  persons,  where  an  atheromatous  state  of  the  blood- 
vessels of  the  brain  exists  before  the  clogging,  the  rapid  softening  that 
may  follow  is  apt  to  be  preceded  by  restlessness,  some  mental  confu- 
sion, and  signs  of  a  general  breaking  up  of  nerve-force  ;  it  is  soon 
associated  with  disturbances  of  the  bladder  and  rectum,  and  leads  to 
coma.  In  the  cases  which  I  have  seen  there  was  neither  much  head- 
ache nor  febrile  disorder. 

In  rare  cases  there  is  a  primary  acute  hemorrhagic  encephalitis 
without  obvious  cause,  though  it  is  likely  that  the  inflammation  starts 
in  the  blood-vessels.  In  its  main  features  it  is  similar  to  the  acute 
encephalitis  of  children,  where,  however,  the  lesion  is  most  apt  to  be 
cortical.  In  the  primary  acute  encephalitis  of  adults  punctiform 
hemorrhages  are  noticed.^  The  chief  symptoms  are  rapidly  develop- 
ing coma  and  hemiplegia.  The  knee-jerks  are  preserved,  though 
there  may  be  crossed  tendon  reflexes  in  the  lower  extremities,  A 
significant  feature  is  the  extraordinarily  high  temperature,  especially 
before  death.  In  the  latter  respect,  it  is  like  what  is  sometmies  ob- 
served in  recent  hemiplegia  following  embolism  or  hemorrhage. 

Intracranial  Tumor. — A  rapidly  growing  tumor  or  one  of  latent 
course  may  give  rise  to  symptoms  resembling  those  of  meningitis,  but 
the  unchanged  or  steadily  increasing  paralysis,  the  marked  optic 
neuritis,  the  progressive  character  of  the  symptoms,  and  the  absence 
of  febrile  phenomena  should  suggest  the  cause. 

JEar  Disease. — Occasionally  disease  of  the  ear,  with  or  without 
extension  to  the  membranes  or  sinuses  of  the  brain,  may  be  attended 
with  deceptive  symptoms,  the  nature  of  which  will  become  clear  upon 
examination  of  the  ear.  In  middle-ear  disease  severe  headache, 
vomiting,  high  fever,  delirium,  convulsions,  and  retraction  of  the  head 
indicate  meningitis  or  abscess. 

Head  Symptoms  of  Continued  Fevers. — In  all  the  varieties  of  con- 
tinued fever,  but  especially  in  typhoid  and  typhus;  cerebral  symptoms 

1  Striimpell,  Deutsch.  Arch.  f.  Klin.  Med.,  Bd.  xlvii.,  1890,  p.  53. 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  159 

at  times  arise  which  bear  a  strong  resemblance  to  those  of  meningitis, 
but  without  even  traces  of  inflammation.  How,  then,  are  we  to 
distinguish  these  fever  cases  from  meningitis?  or  how  ascertain  if 
meningeal  inflammation  be  really  before  us  as  a  complication,  as  it 
sometimes  is,  of  the  fever?  Unfortunately,  there  is  no  sign  abso- 
lutely diagnostic.  Cerebral  auscultation  affords  us  no  help,  for  the 
blowing  sound  that  is  at  times  perceived  is  not  constantly  present  in 
meningitis,  and  may  be  heard  in  health.  As  matters  stand,  a  diag- 
nosis can  be  established  only  by  a  close  consideration  of  all  the 
symptoms,  and  of  the  history,  especially  of  the  onset ;  by  searching 
for  the  eruption  of  typhus  or  typhoid  fever ;  by  a  careful  study  of  the 
temperature  curves ;  and  by  taking  note  of  the  expression  of  the 
countenance.  The  character  of  the  delirium  will  be  of  service  ;  it 
is  ordinarily  much  more  active  when  the  membranes  of  the  brain 
are  inflamed,  and  is  attended  with  throbbing  of  the  arteries  of  the 
neck  and  face, — a  symptom,  however,  not  conclusive,  for  it  may 
be  noticed  in  low  fevers, — and  not  infrequently  with  convulsions. 
The  relation  between  headache  and  delirium  may  be  of  aid.  In 
general '  diseases  headache  ceases  when  delirium  sets  in ;  in  men- 
ingitis the  two  coexist.  Then,  too,  we  may  lay  stress  on  optic 
neuritis  ;  on  retraction  of  the  head,  if  present ;  on  the  more  intense 
headache  ;  on  the  vomiting ;  and  we  may  attach  some,  but  not  too 
great,  importance  to  the  red  line  made  by  drawing  the  nail  across 
the  forehead, — the  meningltic  streak.  The  most  valuable  differential 
sign  is  the  loss  of  the  knee-jerk,  a  loss  that  is  apt  to  happen,  at  least 
temporarily,  in  meningitis. 

Head  Symjitoms  of  Acute  Rheumatism. — The  morbid  manifestations 
are  like  those  of  acute  meningitis  :  restlessness,  headache,  and  violent 
delirium,  succeeded  by  coma ;  besides,  rheumatic  involvement  of  the 
muscles  at  the  back  of  the  neck  may  cause  retraction  of  the  head. 
The  delirium  is  commonly  of  gradual  approach,  but  it  niay  come  on 
suddenly.  Generally  it  does  not  appear  until  the  patient  has  been 
suffering  for  at  least  a  week  with  acute  rheumatism  ;  and  the  sweats 
and  swollen  joints  point  out  the  malady  with  which  it  is  combined. 
Examinations  of  the  head,  in  cases  which  have  proved  rapidly  fatal, 
fail  to  reveal,  save  in  rare  instances,  any  evidences  of  inflammatory 
action  within  the  cranium.  The  abnormal  signs  are,  as  a  rule,  more 
properly  attributable  to  the  rheumatic  poison  seizing  upon  the  brain, 
and  to  the  altered  condition  of  the  blood.  They  are  at  times  found 
to  be  connected  with  the  setting  in  of  inflammation  of  the  membranes 
of  the  heart,  or  of  pneumonia,  or  with  albuminuria,  or  with  plugs  of 


160  MEDICAL  DIAGNOSIS. 

fibrin  in  the  capillaries  of  the  brain,  and  are  frequently  associated 
with  a  very  high  temperature.^ 

Head  Symptoms  of  Acute  Ulcerative  Endocarditis. — The  severe 
headache,  the  delirium,  the  somnolence,  which  may  attend  ulcerative 
endocarditis  cause  it  to  be  confounded  with  meningitis.  Generally, 
however,  the  fever  is  of  a  typhoid  type  ;  and  the  high  temperature, 
the  rigors,  the  marked  swelling  of  the  spleen,  the  absence  of  optic 
neuritis,  are  very  significant,  and  so  are  the  cardiac  murmurs. 

Head  Symptoms  of  Pneumonia;  of  Pericarditis. — In  both  these 
maladies  delirium  may  be  met  with  of  a  character  so  active  as  to 
lead  to  the  belief  that  the  brain  is  involved  in  an  inflammatory  dis- 
ease. The  diagnosis  is  cleared  up  by  a  careful  examination  of  the 
chest.  Then  we  may  lay  stress  on  the  violent  delirium  being  unat- 
tended with  spasmodic  movements  or  with  paralysis.  The  form  of 
pneumonia  which  is  mostly  associated  with  delirium  is  inflammation 
of  the  upper  lobes.  True  meningitis  sometimes  attends  pneumonia, 
and  is  with  great  difficulty  distinguished  from  the  mere  disturbance 
of  the  cerebral  circulation  just  mentioned,  unless  persistent  vomiting, 
and  pressure  on  a  cranial  nerve,  or  optic  neuritis  show  us  the  real 
meaning  of  the  brain  affection. 

Tubercular  Meningitis. — This  is  not  a  rare  disease  in  children. 
It  is  a  meningitis  pre-eminently  of  the  base,  incited  by  the  tubercle 
bacillus. 

The  premonitory  signs  of  the  malady  are  of  great  importance. 
The  child  has  generally  bieen  ailing  for  some  time  ;  is  restless,  peevish, 
sleeps  badly,  complains  of  headache,  and  is  troubled  with  a  frequent, 
short  cough,  and  with  constipation.  To  these  symptoms  are  soon 
added  thirst,  a  slightly  coated  tongue,  vomiting,  a  dry,  feverish  skin, 
an  accelerated  pulse,  and  grinding  of  the  teeth,  constituting  the  promi- 
nent features  of  the  first  stage  of  the  affection.  After  four  or  five 
days  the  second  stage  is  reached,  and  the  brain  symptoms  become 
more  clearly  developed.  The  child  shuns  the  light,  puts  the  hand 
frequently  to  its  head,  and  utters  now  and  then  a  peculiar,  sharp, 
distressing  cry.  At  night  the  headache  becomes  worse,  and  is 
attended  with  fleeting  delirium.  A  slight  strabismus  is  observable, 
and  the  eyeballs  oscillate.  The  pulse  is  very  irregular  in  its  rhythm, 
sometimes  rapid  and  intermitting,  then  slow.     The  vomiting  ceases, 

^  For  a  collection  of  cases,  I  may  refer  to  a  paper  on  Cerebral  Rhenmatism 
which  I  published  in  the  American  Journal  of  the  Medical  Sciences,  Jan.  1875. 
Dr.  Posner,  in  the  German  translation  of  this  book,  points  out  that  the  use  of 
salicylic  acid,  now  so  much  employed,  may  give  rise  to  confusing  cerebral  symp- 
toms, such  as  headache,  vertigo,  hallucinations,  even  delirium. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  16] 

and  there  may  be  a  remission  in  the  symptoms,  with  restored  intelH- 
gence  ;  but  the  pulse  remains  irregular,  the  temperature  is  moderately 
elevated,  the  bowels  are  even  more  constipated  than  before,  and  the 
abdomen  appears  retracted.  The  third  stage  is  one  of  complete 
stupor,  accompanied  or  preceded  by  convulsions.  The  expression  of 
the  face  is  idiotic ;  the  pupils  are  dilated ;  there  is  subsultus,  and  one 
side  of  the  body  is  paralyzed.  Deglutition  is  difficult ;  the  surface  is 
covered  with  cold  sweats.  This  condition  may  last  for  days  ;  repeated 
convulsions  hasten  its  termination. 

Can  we  distinguish  the  formidable  complaint  from  ordinary  menin- 
gitis f  Seldom  from  meningitis  of  the  base ;  generally  from  menin- 
gitis of  the  convexities.  As  regards  the  discrimination  from  the 
former  malady,  we  are  enabled  to  pronounce  the  affection  to  be 
tubercular  meningitis,  if  we  are  familiar  with  the  patient's  antece- 
dents, and  are  cognizant,  previous  to  the  seizure,  of  the  presence  of 
scrofula  of  bones  or  joints,  or  of  tubercle  in  any  of  the  internal 
organs,  or  are  able  at  the  time  to  detect  scrofulous  glands  or  tuber- 
cular phthisis.  But  without  knowledge  of  this  kind  a  positive  diag- 
nosis is  impossible :  we  have  nothing  to  direct  us  except  the  proba- 
bility that  the  case  is  tubercular,  because  most  instances  of  meningitis 
of  the  base  are  of  that  nature.  This  uncertainty  does  not  exist  with 
reference  to  the  usual  form  of  simple  meningeal  inflammation.  We 
may  generally  distinguish  the  tubercular  malady  by  its  occurrence  in 
an  unhealthy  person ;  by  its  insidious  approach ;  by  the  absence  of 
violent  delirium ;  by  the  appearance  of  convulsions,  not  early,  but 
late  in  the  disease ;  by  the  far  less  violent  headache,  and  the  less 
degree  of  febrile  excitement ;  by  the  notable  remissions  in  several 
of  the  cerebral  signs  ;  by  the  chest  symptoms,  and  the  long  duration 
of  the  affection.  The  ophthalmoscope  gives  no  certain  information ; 
tubercles  are  not  commonly  found  in  the  eye-ground,  only  optic 
neuritis  or  choked  disks. 

Tubercular  meningitis  is  ordinarily  attended  with  an  effusion  of 
serum  into  the  ventricles,  and  it  is  plain  that  many  of  the  symptoms 
are  attributable  to  pressure  of  the  fluid  on  portions  of  the  brain. 
Now,  how  can  we  separate  the  malady,  acute  hydrocephalus  as  it 
used  to  be  called,  from  dropsy  of  the  brain  or  chronic  hydrocepha- 
lus f  Partly  by  the  history  of  the  case,  and  partly  by  the  normal 
size  of  the  head ;  for  the  water  on  the  brain  is  not  sufficient  in 
amount  nor  is  it  there  long  enough  to  produce  an  appreciable  aug- 
mentation of  the  cranium.  Then,  in  chronic  hydrocephalus  the 
symptoms  manifest  themselves  for  years,  from  childhood  even  to 
adult  life.     The  signs  of  a  profound  cerebral  lesion  appear  gradually. 


162  MEDICAL  DIAGNOSIS. 

the  special  senses  are  by  degrees  enfeebled,  but  it  is  a  long  time  before 
they  are  wholly  abolished,  or  before  complete  loss  of  consciousness 
takes  place. 

As  regards  the  diagnosis  between  tubercular  meningitis  and  acute 
hydrocephalus,  it  need  only  be  stated  that  the  latter  affection  is  in 
the  vast  majority  of  cases  a  synonym  for  the  former.  Yet  we  occa- 
sionally meet  with  instances  in  which  acute  hydrocephalus  occurs 
unconnected  with  tubercle.  It  runs  then  either  a  latent  course,  or 
appears  as  an  acute  malady  with  symptoms  similar  to  those  of  acute 
meningitis,  a  serous  meningitis,  beginning  with  fever  or  with  convul- 
sions, and  often  attended  with  marked  choked  disks,  with  intense 
restlessness,  succeeded  by  drowsiness,  and  having  periods  of  inter- 
mission of  the  symptoms  and  of  apparent  improvement ;  the  pulse 
and  temperature  show  great  variations.  Towards  the  end  severe 
convulsions  are  common.  The  complaint,  unlike  tubercular  menin- 
gitis, happens  in  previously  healthy  children,  begins  suddenly,  and  is 
of  short  duration.  But  the  effusion  may  remain,  and  the  disorder 
lead  to  chronic  hydrocephalus. 

There  is  a  functional  disturbance  of  the  brain  to  discriminate 
from  tubercular  meningitis, — the  hydrocephaloid  disease  described  by 
Marshall  Hall.  It  has  a  stage  in  which  the  little  patient  is  restless 
and  feverish,  and  a  stage  in  which  the  countenance  becomes  pale, 
the  breathing  irregular,  the  voice  husky,  the  pupils  dilated  and  unin- 
fluenced by  light,  and  in  which  somnolence,  coma,  and  even  general 
convulsions  occur.  The  symptoms  indicate  cerebral  anaemia  and 
nervous  exhaustion.  They  generally  come  on  after  an  enfeebling 
attack  of  illness,  especially  subsequent  to  protracted  diarrhoea  or 
loss  of  blood ;  sometimes  they  follow  premature  weaning.  In  the 
history  of  the  case ;  in  the  less  tendency  to  vomiting ;  in  the  irreg- 
ularity of  the  pulse ;  in  the  flaccid  and  hollow  state  of  the  fontanel, 
so  dissimilar  to  its  prominent  and  tense  condition  in  inflammation  ; 
and  in  the  arrest  of  the  threatening  signs  by  stimulants  and  by 
tonics, — we  find  the  guides  which  enable  us  to  decide  against  the 
existence  of  an  organic  disease  of  the  brain  or  its  membranes. 

But  other  affections  besides  those  of  the  brain  may  be  confounded 
with  tubercular  meningitis,  such  as  typhoid  fever  and  pneumonia. 
From  typhoid  fever  tubercular  meningitis  may  be  distinguished  by  the 
frequent  vomiting ;  by  the  retracted  abdomen  ;  by  the  constipation, 
except  in  instances  of  coexisting  acute  intestinal  tuberculosis  ;  by  the 
normal  size  of  the  spleen  ;  by  the  irregularity  of  the  pulse  ;  by  the  oc- 
currence of  convulsions  and  anaesthesia,  and  other  signs  of  profound 
motor  and  sensory  disturbance  ;  by  the  lower  heat,  the  thermometer 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  163 

seldom  rising  above  102°  ;  by  the  absence  of  the  serum-reaction  of 
the  Widal  test.  I  have  never  seen  an  eruption  in  tubercular  menin- 
gitis ;  but  Barthez  and  Rilliet  speak  of  fugitive,  imperfectly  formed 
rose-spots  being  present  in  rare  cases.  The  duration  of  the  two 
complaints  affords  no  help  in  diagnosis,  since  the  one  may  last  as 
long  as  the  other. 

Tubercular  meningitis  may  be  confounded  with  the  acute  affec- 
tions of  the  lungs,  especially  acute  pneumonia,  which,  in  children  es- 
pecially, are  not  uncommonly  associated  with  delirium  and  other  brain 
symptoms.  But  the  temperature  is  much  higher ;  and  a  close  ex- 
amination of  the  chest  reveals  the  cause  of  the  disturbance  of  the 
brain.  As  regards  acute  phthisis  the  difficulty  is  sometimes  great, 
for  there  may  be  in  tubercular  meningitis  also  signs  of  tubercular 
deposition  in  the  lungs.  The  high  temperature  of  acute  tuberculosis 
and  the  course  of  the  cerebral  symptoms,  should  these  be  present, 
would  alone  be  conclusive.  As  a  point  in  the  diagnosis  of  the  tuber- 
cular meningitis  of  children,  with  reference  to  the  attending  chest 
symptoms,  Gee^  mentions  that  the  chest  heaves  equally  on  both 
sides,  yet  over  a  very  large  part,  or  even  the  whole,  of  one  side,  no 
respiratory  sound  is  heard. 

Tubercular  meningitis  is  not  so  rare  in  adults  as  has  been  sup- 
posed, and  presents,  as  Seitz  in  his  admirable  monograph  has  shown, 
marked  features  of  pain  in  the  head  and  temperature  variations,^  ex- 
hibiting a  fever  of  moderate  type,  with  irregular  remissions.  The 
deposit  of  tubercle  both  in  adults  and  in  children  may  not  be  con- 
fined to  the  head.  Indeed,  the  observations  of  LioriUi^  teach  that 
the  spinal  cord  is  frequently  implicated. 

The  points  of  differential  diagnosis  of  the  tubercular  meningitis 
of  adults  are  much  the  same  as  with  reference  to  the  disease  in 
childhood.  Yet  one  disorder  is  more  apt  to  be  confounded  with  it, — 
hysteria.  Indeed,  in  young  women  the  onset  of  the  malady  may  de- 
velop very  misleading  hysterical  symptoms.  But  on  close  examina- 
tion we  find  the  traits  of  the  cerebral  malady, — the  temperature 
record  of  the  attending  fever,  the  unequal  pupils,  the  divergent  stra- 
bismus, the  optic  neuritis,  the  trophic  changes  in  the  skin,  the  incon- 
tinence of  urine,  the  local  beginning  of  the  convulsions. 

Cerebro-Spinal  Meningitis.- — Now  and  then  cases  of  menin- 
gitis are  encountered  in  which  the  inflammation  affects  simultane- 

^  Reynolds's  System  of  Medicine,  vol.  ii. 

^  Die  Meningitis  tuberculosa  der  Erwachsenen. 

•^  Archives  de  Physiologic,  1870. 


164  MEDICAL   DIAGNOSIS. 

ously  the  membranes  of  the  brain  and  of  the  spine,  and  in  which  the 
symptoms  of  the  cerebral  malady  are  found  to  be  blended  with 
severe  pain  along  the  vertebral  column,  with  retraction  of  the  head, 
with  convulsions,  with  rigidity  of  the  muscles,  with  perverted  cutane- 
ous sensibility, — in  short,  with  the  phenomena  denoting  spinal  menin- 
gitis. But  such  sporadic  cases  are  of  rare  occurrence.  Generally 
cerebro-spinal  meningitis  is  not  met  with  save  as  an  epidemic  disease 
that  belongs  clearly  to  the  group  of  fevers,  with  which  it  will  be  de- 
scribed. But  here  may  be  pointed  out  the  extreme  difficulty  of 
recognition  of  the  sporadic  non-epidemic  cases.  The  early  retraction 
of  the  head,  the  eruption,  the  temperature  record  of  cerebro-spinal 
fever,  the  bacteriological  results  of  lumbar  puncture,  are  the  most 
valuable  diagnostic  signs.  Pneumonia,  so  common  in  this,  may,  as 
some  cases  mentioned  by  Gowers  prove,  also  happen  in  the  sporadic 
malady. 

Delirium  Tremens. — The  prominent  trait  of  this  complaint  is 
delirium,  associated  with  trembling  and  with  sleeplessness.  It  occurs 
in  intemperate  persons  ;  yist  such  is  not  alw^ays  the  case,  for  we  may 
find  an  affection  identical  with  mania  a  potu  in  those  who  are  not  in- 
temperate in  the  ordinary  acceptation  of  the  word,  but  whose  ner- 
vous system  has  been  racked  by  persistent  mental  anxiety,  or  by  the 
use  of  other  than  alcoholic  stimulants.  I  have  seen  such  cases  from 
the  constant  taking  of  chloral  and  of  paraldehyde ;  and  they  may  be 
noticed  in  morphine-takers. 

Generally,  however,  delirium  tremens  is  brought  on  by  the  abuse 
of  intoxicating  liquors.  It  is  a  current  belief,  and  one  which  has 
found  much  favor  among  habitual  drinkers,  that  a  diminution  or  a 
sudden  discontinuance  of  the  accustomed  beverage  is  followed  by  an 
onset  of  delirium.  This  may  happen  ;  but  it  is  generally  the  reverse  ; 
it  is  a  long-continued  and  unusually  severe  debauch  which  terminates 
in  an  attack  of  mania. 

Let  us  look  a  little  more  closely  at  the  mental  wandering.  It  is 
very  rarely  fierce ;  nor  is  the  patient  taken  up  wholly  with  his  delu- 
sions. He  pays  a  certain  amount  of  attention  to  surrounding  objects, 
answers,  perhaps  in  a  rambling  manner,  the  questions  put  to  him, 
but  fancies  that  animals  are  running  around  on  his  bed  or  are  crawl- 
ing on  the  walls,  and  is  thereby,  or  by  some  equally  distressing  illu- 
sion, kept  in  horror  and  in  dread.  Or  he  imagines  himself  to  be  en- 
gaged in  his  ordinary  occupations,  and  gives  minute  directions  as  to 
what  he  wishes  done  ;  tries  to  get  out  of  bed,  yet  is  quite  tractable 
when  thwarted  in  his  efforts.  He  is  very  restless,  his  hands  are  con- 
stantly moving,  and  his  delirium,  to  use  the  graphic  epithet  of  Watson, 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  165 

is  a  busy  one.  With  it  are  associated  sleeplessness,  a  frequent,  soft 
pulse,  utter  loss  of  appetite,  a  moist,  coated  tongue,  and  a  clammy 
skin.  The  tremor  is  irregular,  wide  in  range,  affects  particularly  the 
arms,  face,  and  tongue,  and  is  only  induced  on  attempted  movement. 
There  is  often,  besides,  spontaneous  muscular  twitching.  The  tem- 
perature is  usually  elevated,  though  rarely  to  a  considerable  degree ; 
it  seldom  reaches  103°  F. 

How  are  we  to  distinguish  the  malady  from  one  to  which  it  bears 
a  certain  resemblance, — acute  meningitis  f  Taking  clearly  expressed 
examples  of  each,  we  find  the  following  marks  of  distinction  :  the  pulse 
is  different ;  tense  and  hard  in  meningeal  inflammation,  it  is  yielding 
and  soft  in  delirium  tremens.  The  skin  and  tongue  are  dry  and 
feverish  in  the  former  affection,  moist  in  the  latter.  Then  the  char- 
acteristics of  the  delirium  are  dissimilar :  and  in  the  one  disease  the 
mental  wandering  is  combined  with  severe  headache,  but  not  with 
tremors ;  in  the  other,  with  tremors,  but  not  with  headache. 

Yet  in  actual  practice  the  diagnosis  is  not  always  so  easy  as  it  might 
appear  to  be  at  first  sight,  and  here  and  there  we  meet  with  cases 
presenting  symptoms  the  exact  meaning  of  which  it  is  puzzling  to 
determine.  The  difficulty  is  mainly  occasioned  by  extreme  cerebral 
congestion,  or  by  inflammatory  action,  having  been  produced  by  the 
same  exciting  cause  that  has  brought  on  delirium  tremens.  In  this 
blending  of  two  morbid  states,  the  pulse  is,  or  soon  becomes,  tenser 
than  in  pure  mania  a  potu  ;  the  temperature  is  apt  to  be  higher,  and 
the  irritability  of  the  stomach  more  marked  and  more  persistent.  In 
some  instances,  convulsions,  strabismus,  and  deep  stupor — carefully 
to  be  distinguished  from  the  sleep  which  often  announces  the  termi- 
nation of  mania  a  potu — set  all  doubt  at  rest.  But  when  these  signs 
are  not  present,  we  have  to  judge  of  the  mischief  that  is  going  on 
within  the  cranium  chiefly  by  the  activity  of  the  fever  and  by  the 
appearances  of  the  eye-ground,  by  finding  choking  of  the  disks.  Yet 
caution  is  necessary  in  accepting  as  evidence  phenomena  which  may 
be  of  diverse  origin :  the  marked  fever  may  be  the  result  of,  what  is 
very  frequent  in  delirium  tremens,  an  intercurrent  or  coexisting  pneu- 
monia, or  of  a  pulmonary  apoplexy,  as  in  a  case  I  have  seen.  Then, 
again,  we  must  not  overlook  the  fact  that  in  instances  of  pneumonia  of 
the  apex  a  delirium  very  similar  to"  that  of  mania  a  potu  may  happen. 

There  is  another  point  connected  with  the  diagnosis  of  the  malady 
which  it  is  necessary  to  mention,  and  chiefly  for  the  purpose  of  calling 
attention  to  a  common  error.  The  fact  that  a  person  known  to  be  of 
bad  habits  is  affected  with  delirium  is  received  as  a  sure  indication 
that  the  mental  delusions  have  been  produced  by  the  abuse  of  ardent 


166  •  MEDICAL   DIAGNOSIS. 

spirits.  But  they  may  be  owing  to  other  causes  :  to  fever,  to  a  vis- 
ceral inflammation ;  to  acute  mania.  To  avoid  being  deceived,  we 
must  lay  stress  rather  on  the  special  character  of  the  delirium,  and  on 
the  symptoms  with  which  it  is  combined,  than  on  its  mere  presence. 
In  other  words,  delirium  in  inebriates  is  not  of  necessity  the  fruit  of 
intemperance.  In  discussing  acute  mania  we  shall  return  to  this 
subject. 

When  delirium  tremens  ends  fatally,  death  takes  place  from  •  ex- 
haustion. The  fatal  issue  is  occasionally  brought  on  by  an  inter- 
current inflammation,  especially  of  the  lung,  or  by  disease  of  the 
kidneys  and  uraemia.  Sometimes,  after  the  subsidence  of  the  urgent 
cerebral  symptoms,  the  patient  dies  very  unexpectedly,  and  there  are 
no  morbid  appearances  in  the  brain  or  its  membranes  to  account  for 
the  ai)rupt  extinction  of  life.  In  many  instances  of  these  sudden 
deaths,  a  large  amount  of  serum  is  found  in  the  ventricles,  or  in  the 
subarachnoid  spaces. 

Acute  Mania. — It  would  be  out  of  place  to  attempt  to  give,  in  a 
work  of  this  kind,  a  detailed  account  of  any  of  the  forms  of  insanity ; 
but,  in  its  acute  variety  especially,  it  resembles  other  affections  of  the 
nervous  system  so  closely  that  it  cannot  be  wholly  passed  over. 

There  are  two  disorders  with  which  acute  mania  is  chiefly  liable 
to  be  confounded, — acute  meningitis  and  delirium  tremens  ;  and  we 
shall  for  our  purposes  best  learn  the  manifestations  of  acute  mania  by 
contrasting  it  with  these  maladies. 

From  acute  meningitis  mania  differs  in  these  essential  particulars  : 
the  premonitory  symptoms  of  the  former  are  headache,  drowsiness, 
and  often  a  sense  of  tingling  and  of  numbness  in  the  extremities  ; 
these  signs  are,  however,  soon  succeeded  by  the  severe  headache, 
tense  pulse,  decided  fever,  and  optical  illusions  of  the  developed  dis- 
ease. The  premonitory  symptoms  of  acute  mania,  on  the  other  hand, 
have  generally  existed  for  a  longer  time  before  the  marked  outbreak ; 
some  singular  change  of  manner  or  of  mode  of  thought  commonly 
precedes  the  first  violent  attack  of  insanity,  except  in  those  cases  in 
which  the  overthrow  of  reason  results  from  a  sudden,  great  grief,  or 
from  a  violent  shock  to  the  nervous  system.  Further,  when  the 
delusions  have  taken  full  possession  of  the  mind,  the  patient  attempts 
to  act  up  to  them,  and  his  bodily  strength  enables  him  to  do  so.  He 
has  little  if  any  fever  ;  no  .spasms  ;  his  pupils  are  not  contracted  ;  his 
stomach  is  not  irritable  ;  he  does  not  suffer  from  headache,  or  at  least 
does  not  complain  of  his  head.  It  is  needless  to  point  out  how  all 
this  differs  from  acute  inflammation  of  the  brain. 

There  is  but  little  difficulty  in  discriminating  between  typical  cases 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  167 

of  delirium  tremens  and  of  acute  mania.  The  anxious  countenance,  the 
alarm,  the  good-natured  loquacity  and  restlessness  of  the  patient,  his 
moist  skin,  compressible  pulse,  and  creamy  tongue,  are  very  different 
from  the  ravings  and  excitement,  or  the  stubborn  silence  alternating 
with  the  wild  hallucinations,  of  insanity.  Yet  there  are  cases  in  which 
it  is  not  easy  to  tell  if  the  delusions  are  really  due  to  intemperance : 
cases  of  insanity  excited  by  drink  in  persons  predisposed  to  mania. 
A  few  days,  however,  ordinarily  remove  all  uncertainty :  the  person 
who  was  thought  to  be  merely  delirious  is  seen  to  become  frantic  after 
an  intermission  of  quiet,  or,  unlike  what  happens  in  mania  a  potu,  to 
be  still  out  of  his  mind  after  he  has  had  several  sound  sleeps.  In  one 
instance  I  met  with,  in  which  much  doubt  existed  as  to  the  diagnosis, 
the  patient  solved  the  doubt  by  jumping  out  of  bed  after  having  been 
quietly  sleeping  for  hours,  and,  in  a  state  of  wild  excitement,  knocking 
down  the  nurse  who  tried  to  prevent  her  from  leaving  the  room. 
Furthermore,  in  acute  alcoholic  mania  there  is  a  strong  tendency  to 
homicide,  while  in  acute  melancholia  induced  by  drink  the  tendency  is 
to  suicide. 

Diseases  marked  by  Sudden  Loss  of  Consciousness  and  of 

Voluntary  Motion. 

The  chief  diseases  of  this  class  are  apoplexy,  sunstroke,  and  cata- 
lepsy. Epilepsy,  too,  might  be  here  regarded ;  but  it  will  be  more 
convenient  to  consider  it  with  the  convulsive  affections. 

Apoplexy. — This  is  coma  coming  on  rapidly,  and  occurring 
nearly  always  as  a  result  of  intracerebral  hemorrhage.  It  may  be, 
however,  also  caused  by  sudden  arrest  of  the  blood-supply  to  the 
brain,  by  concussion,  by  congestion,  and  by  laceration  of  the  brain. 
Disease  of  the  blood-vessels  and  miliary  aneurisms  are  very  commonly 
present,  or  we  observe  the  malady  in  affections  in  which  hemorrhages 
are  prone  to  happen,  such  as  in  purpura,  in  scurvy,  in  pernicious 
anaemia,  in  leukaemia. 

The  malady  has  sometimes  no  prodromata ;  but  not  unfrequently 
it  is  preceded  by  great  depression  of  spirits,  by  attacks  of  loss  of 
memory,  by  illusions,  by  vitiated  perceptions,  by  vertigo,  by  odd  sen- 
sations in  the  head,  or  by  one-sided  weakness  or  numbness.  The 
seizure  is  generally  sudden,  and  the  coma  quickly  developed.  The 
patient  falls  to  the  ground,  bereft  of  all  consciousness.  In  other  in- 
stances, before  he  sinks  into  the  comatose  sleep,  there  will  be  more  or 
less  pain  in  the  head,  sickness  at  the  stomach,  heaviness  and  confusion 
of  thought,  or  even  slight  convulsions.  Again,  we  may  have  convul- 
sions a  prominent  feature  almost  from  the  onset. 


168  MEDICAL   DIAGNOSIS. 

When,  whatever  the  beginning,  the  attack  has  reached  its  height, 
it  presents  these  well-known  features :  the  patient  lies  as  if  in  a  deep 
sleep,  breathing  laboriously  and  noisily,  and  each  snoring  inspiration  is 
slow,  followed  by  a  flapping  of  the  cheeks  in  expiration.  The  pulse  is 
slow,  full,  at  times  irregular ;  the  carotids  throb  violently,  and  the  in- 
creased pulsation  is  particularly  noticed  in  large  extravasations  ;  there 
is  difficulty  of  deglutition ;  the  pupils  are  immovable,  and  either  con- 
tracted or  dilated  ;  the  eye  is  half  open ;  there  is  conjugate  deviation. 
All  thought,  all  sensation,  all  volition  is  suspended ;  the  limbs  are 
motionless,  flaccid,  and,  when  lifted,  fall  passively  and  to  all  appear- 
ances lifeless  to  the  ground.  Occasionally  their  muscles  are  rigid ; 
but  generally  reflex  irritability,  superficial  and  deep,  is  lost.  When 
this  returns  it  appears  on  the  unparalyzed  side  first.  In  severe  cases 
the  insensibility  becomes  greater,  the  breathing  very  irregular  and 
of  the  Cheyne- Stokes  variety,  and  involuntary  discharges  take  place 
from  the  bladder  and  rectum. 

If  the  patient  recover  from  the  comatose  state,  he  does  so  gener- 
ally in  a  short  time :  in  a  few  hours,  unless  the  lesion  be  very  great, 
the  intellectual  faculties  begin  to  resume  their  sway,  and  all  the  func- 
tions of  the  body  are  slowly  restored  to  their  natural  condition.  Yet 
there  is  a  palpable  exception  to  this  in  the  muscular  system.  Paral- 
ysis of  one  side  is  apt  to  remain.  The  urine  may  be  increased  in 
amount  and  it  may  contain  albumin  and  even  sugar. 

The  temperature  variations  in  apoplexy  may  be  turned  to  useful 
diagnostic  account.  The  temperature  of  the  body  is  at  first  somewhat 
lowered,  but  this  is  followed  by  a  stationary  normal  period,  and  not 
unfrequently  by  a  rapid  rise,  which  again,  as  the  patient  recovers,  is 
succeeded  by  a  return  to  the  natural  body  heat.  In  severe  cases, 
where  large  hemorrhages  take  place,  the  temperature  seldom  rises,  or 
only  rises  to  fall  with  the  recurrence  of  the  fatal  bleeding,  yet  some 
apoplectic  lesions  of  the  pons  and  the  medulla  are  throughout  at- 
tended with  elevation  of  temperature.  If  the  stationary  period  be 
short  or  absent,  and  the  body  heat  rise  therefore  almost  continuously 
after  the  primary  depression,  the  prospects  of  recovery  are  gloomy. 
From  Dana's  elaborate  study ,^  we  know,  indeed,  that  in  fatal  cases  of 
apoplexy  a  rise  of  rectal  temperature  to  from  100°  to  102°  F.  occurs, 
as  a  rule,  on  the  first  day  after  the  seizure.  On  the  second  day,  if  the 
case  be  not  immediately  fatal,  the  temperature  falls  a  little,  averaging 
101°  or  101 .5°.  As  regards  the  surface  temperature,  it  is  noted  that  in 
instances  of  extensive  intracranial  hemorrhage  the  temperature  upon 

^  Amer.  Journ.  Med.  Sci.,  June,  1894. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  169 

the  paralyzed  side   is   somewhat  higher  than  upon  the  sound  side, 
while  in  cases  of  thrombosis  or  embolism  there  is  no  such  difference. 

Apoplexy  is  very  apt  to  happen  after  dinner  and  during  sleep,  and 
is  most  common  during  sudden  changes  of  temperature.  Liddell  has 
shown  that  attacks  are  more  usual  in  the  spring.  In  New  York  he 
found  the  mortality  greatest  at  this  time  of  year.^  One  attack  of 
apoplexy  is  likely,  sooner  or  later,  to  be  followed  by  another ;  and 
the  -reason  of  this  is,  that  the  predisposing  cause  is  usually  of  a  per- 
sistent character, — an  organic  cardiac  malady,  especially  hypertro- 
phy ;  Bright's  disease ;  degeneration  of  the  cerebral  arteries ;  dis- 
seminated sclerosis,  or  softening  of  the  brain.  It  is  likely  that  the 
extravasation  of  blood  is  generally  due  to  the  same  immediate  cause, 
— to  rupture  of  miliary  aneurisms  on  the  minute  diseased  arteries. 

Now,  is  there  anything  at  the  time  of  the  apoplexy,  or  after  its 
most  urgent  symptoms  have  passed  away,  by  which  we  can  recognize 
whether  the  pressure  on  the  brain  results  from  a  clot,  from  vascular 
obstruction,  or  from  turgescence  of  the  cerebral  vessels  ?  And,  again, 
do  the  morbid  manifestations  furnish  any  clue  to  the  seat  of  the  hem- 
orrhage ?  With  reference  to  the  former  question,  all  clinical  experi- 
ence forces  us  to  admit  that,  in  any  of  the  states  mentioned,  the  actual 
signs  may  be  the  same,  and  that  we  never  can  be  quite  certain  of  the 
non-existence  of  a  clot.  It  is  true  that  when  the  apoplectic  symptoms 
abate  rapidly  ;  when  thought,  however  confused,  soon  returns  ;  when 
the  limbs  are  not  paralyzed,  or  are  so  but  ifnperfectly  and  for  a  short 
time,  we  have  strong  reason  for  believing  that  congestion,  only,  lies 
at  the  root  of  the  disturbance ;  that,  in  other  words,  the  case  is  one 
of  those  called  simple  apoplexy.  But  it  is  never  possDDle  to  give  a 
positive  opinion,  since  a  clot  near  the  periphery  of  the  brain  may 
occasion  the  same  phenomena  as  those  specified.  Attacks  of  cerebral 
congestion  with  apoplectic  symptoms  happen  in  the  general  paralysis 
of  the  insane.     The  features  of  this  point  out  their  nature. 

With  regard  to  a  rapid  effusion  of  serum,  the  difficulty  of  distinc- 
tion from  hemorrhage  is  very  great.  In  fact,  the  only  differential 
signs  which  were  formerly  claimed  for  serous  apoplexy — namely,  pallor 
of  face  and  feebleness  of  pulse — are  common  in  large  sanguineous  effu- 
sions ;  and  we  find  absolutely  no  sign  that  can  be  looked  upon  as  con- 
clusive. Most  of  the  cases  of  so-called  serous  apoplexy  are  instances 
of  Bright's  disease  with  serous  effusion  into  the  brain,  and  the  very 
existence  of  the  disease  is  now,  for  the  most  part,  denied. 

The  seat  of  the  hemorrhage  can  be  detected  with  more  certainty 

^  Treatise  on  Apoplexy,  New  York,  1873. 
11 


170  MEDICAL   DIAGNPSIS. 

than  the  cause  of  the  cerebral  pressure  ;  it  could  be  detected  with 
greater  certainty  were  it  not  that  the  extravasation  so  often  takes 
place  into  an  already  diseased  brain.  The  order  of  frequency  in 
which  hemorrhage  occurs  into  various  parts  of  the  brain  is  as  fol- 
lows :  central  ganglia,  cerebrum  ovale,  cortex,  pons,  cerebellum,  me- 
dulla, crus  cerebri.  In  the  majority  of  instances  the  blood  is  effused 
into  one  of  the  corpora  striata  and  the  internal  capsule,  or  at  the  same 
time  into  the  optic  thalami,  and  we  find  only  one-sided  paralysis.  If 
the  lesion  be  in  both  hemispheres,  the  palsy  is  on  both  sides  of  the 
body,  although  more  complete  on  one  side  than  on  the  other.  Yet  a 
double-sided  palsy  does  not  justify  an  absolute  opinion  that  the  ex- 
travasation of  blood  into  the  brain-substance  is  double-sided  ;  it  be- 
tokens also  an  extravasation  into  the  ventricles.  But  ventricular  hem- 
orrhage is  distinguished  by  profound  coma  and  by  tonic  contraction  of 
the  muscles,  or  by  tonic  alternating  with  clonic  spasms,  and  rigidity 
of  the  muscles  either  on  one  or  on  both  sides  occurs  ;  the  respiration 
is  much  embarrassed,  and  the  breath-sounds  are  obscured  by  rales. 
It  is  common  in  the  very  young  and  in  the  old,  and  paralysis  is  fre- 
quently absent,  though  it  may  be  general.^  Ventricular  hemorrhage 
is  more  often  secondary  than  prmiary,  the  blood  having  torn  its  way 
into  the  cavity.  Hemorrhage  limited  to  the  thalamus  may  give  rise 
to  no  symptoms  unless  the  internal  capsule  be  damaged,  when  slight 
hemiplegia,  hemiansesthesia,  and  hemianopsia,  with  mobile  spasm  and 
motor  incoordination,  are  apt  to  show  themselves. 

Hemorrhage  into  the  corpora  quadrigemina  presents  most  frecfuently 
this  combination  of  symptoms :  muscular  incoordination,  mipairment 
of  sight  and  alteration  of  the  pupils.  Cerebellar  hemorrhage  gives  rise  to 
very  temporary  loss  of  consciousness,  to  unsteadiness  of  movement, 
and  to  frequent  vomiting  ;  vision  is  not  affected.  In  instances  in  which 
there  is  hemiplegia  it  may  or  may  not  be  on  the  same  side  as  the  lesion. 
In  hemorrhage  into  one-half  of  the  pons,  there  is  palsy  of  the  extremi- 
ties on  one  side,  and  of  the  face  on  the  other.-  The  pupils  are  often 
contracted,  though  they  may  be  dilated  and  inactive.  Disturbance  of 
respiration  is  common.  In  lesions  of  the  pons,  too,  as  in  those  of  the 
medulla,  we  have  high  arid  rapidly  rising  temperature  almost  from  the 
onset,  and  we  find  an  exception  to  the  rule  that  the  lateral  deviation 
of  the  eyes  and  head,  a  sign  so  commonly  present  in  apoplexy,  is 
towards  the  side  of  the  brain  affection.'^      Anpesthesia  and  double- 

^  Sanders,  Amer.  Journ.  Med.  Sci.,  July,  1881. 
^  Gubler,  Gazette  Hebdomadaire,  1858,  1859. 
^  Bastian,  Paralysis  from  Brain  Disease. 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  171 

sided  palsy  are  often  met  with,  and  initial  convulsions  are  very  com- 
mon, and  are  sometimes  limited  to  the  legs.  There  is  vomiting  as 
well  as  hyperpyrexia.  Hemorrhage  into  the  medulla  is  almost  always 
immediately  fatal ;  should  the  patient  survive,  symptoms  of  bulbar 
paralysis  will  be  present. 

In  cortical  bleedings  we  are  apt  to  have  localized  convulsions  and 
but  slight  palsy.  Extravasation  into  the  cerebrum  ovale  gives  rise  to 
similar  symptoms,  if  it  occur  just  beneath  the  cortex.  Hemorrhage 
limited  to  one  crus  cerebri  cause's  paralysis  of  the  extremities  on  the 
opposite  side  and  of  the  third  nerve  on  the  same  side  as  the  lesion. 
Hemorrhage  limited  to  the  arachnoid,  with  the  blood  poured  into  the 
subarachnoid  spaces,  occasions  ordinarily  pain  in  the  head,  somno- 
lency, and  profound  coma  without  paralysis,  and  without  anaesthesia 
or  slow  pulse,  but  with  relaxation  of  the  muscles,  and  sometimes  with 
convulsions ;  now  and  then  the  symptoms  assume,  to  all  appearance, 
a  remittent  course.  It  is  a  very  fatal  form  of  apoplexy,  occurring 
chiefly  in  new-born  children,  and  after  injuries  to  the  head,  or  from 
the  giving  way  of  a  diseased  and  widened  artery,  or  in  consequence 
of  a  rupture  of  one  of  the  sinuses  of  the  dura  mater. 

When  the  effusion  of  blood  takes  place  between  the  dura  mater 
and  the  arachnoid,  it  is  generally  the  ultimate  result  of  an  inflamma- 
tion and  of  subsequent  changes  of  the  mner  surface  of  the  dura 
mater ;  and  on  close  inquiry  the  precursory  symptoms  of  a  disease 
of  the  membrane  may  be  traced,  perhaps,  by  the  constant  and  local- 
ized pain,  and  the  nocturnal  restlessness.  But  the  symptoms  of  the 
hemorrhagic  pachymeningitis  or  hcematoma  are  obscure.  It  happens 
generally  after  fifty  years  of  age,  in  the  decrepit,  in  the  insane,  or  in 
those  suffering  from  pernicious  ansemia,  scurvy,  emphysema,  whooping- 
cough,  alcoholism,  or  after  head  injuries.  When  the  cyst  ruptures  in 
the  thickened  membrane,  which  it  may  not  do  for  years,  the  signs  are 
those  of  an  apoplectic  condition,  lasting  for  eight  or  ten  days.  Head- 
ache, vomiting,  nystagmus,  and  optic  neuritis  are  among  the  main 
symptoms. 

Let  us  now  inquire  how  the  diagnosis  of  apoplexy  can  be  deter- 
mined, and  how  this  condition  may  be  distinguished  from  other 
states  which  produce  rapid  loss  of  consciousness,  or  sudden  paralysis. 
Not  to  mention  epilepsy, — the  phenomena  of  which  we  shall  farther 
on  contrast  with  those  of  apoplexy,  and  shall  observe  to  differ  chiefly 
in  the  prominence  of  the  convulsive  seizures ;  or  meningitis, — in 
which  fever,  headache,  and  other  signs  of  an  acute  cerebral  disease 
precede  insensibility  ;  or  a  tumor, — which,  save  in  the  rarest  instances, 
leads  only  very  gradually  to  a  comatose  condition :  or  sunstroke, — 


172  MEDICAL   DIAGNOSIS. 

exhibiting  insensibility,  yet  also  presenting  points  of  contrast  that  will 
shortly  engage  our  attention, — we  find,  excluding  concussion  and 
compression  from  injury,  these  morbid  states  liable  to  be  mistaken 
for  cerebral  hemorrhage : 

Obstructions  of  the  Cerebral  Arteries  ; 

Insensibility  from  Drink,  or  from  Narcotic  Poisons  ; 

Urj:mia  ; 

Diabetic  Coma  ; 

Syncope  ; 

Asphyxia  ; 

Acute  Softening  ; 

Sudden  Extensive  Paralysis  ; 

Protracted  Sleep ; 

Cerebral  Hysteria. 

Obstructions  of  the  Cerebral  Arteries. — Cerebral  embolism  or  cere- 
bral thrombosis  will  produce  symptoms  so  similar  to  hemorrhage 
that  in  every  case  of  apoplexy  we  must  ask  ourselves  the  question 
whether  the  coma  be  due  to  obstruction  of  the  vessels  or  to  their 
rupture.  We  may  suspect  arterial  obstruction  if  the  patient  be  young 
or  in  middle  life  ;  if  there  be  signs  of  a  similar  condition  elsewhere  ; 
or  if  he  be  laboring  under  endocardial  inflammation,  or  a  chronic 
valvular  affection  in  which  fragments  of  vegetations  may  be  broken 
off  and  washed  into  the  vessels  of  the  brain  ;  or  if  there  be  evidence 
of  atheromatous  disease  of  the  arteries,  or  of  syphilitic  inflammation 
of  the  coats  of  the  vessels ;  or  if  -within  a  brief  period  several 
incomplete  attacks  have  occurred  before  a  completely  comatose 
condition  sets  in.  The  usual  locality  of  the  impaction  is  in  the  middle 
cerebral  artery  ;  and  the  consequences  of  the  interrupted  circulation 
are  at  once  perceived  in  the  motor  area  of  the  cortex  or  in  the  in- 
ternal capsule.  The  interference  with  the  circulation  through  the 
obstructed  vessels  gives  rise  to  necrotic  softening  in  the  area 
deprived  of  blood.  The  palsy  which  ensues  in  connection  with  the 
apparently  apoplectic  phenomena  is,  with  few  exceptions,  one-sided ; 
not  infrequently  it  is  limited  to  one  member  ;  and  the  facial  paralysis 
is  on  the  same  side  with  the  paralysis  of  the  limbs.  Unlike  what 
happens  in  cerebral  hemorrhage,  little,  if  any,  fall  of  temperature 
occurs,  but  there  are  subsequently  decided  fever  and  severe  head- 
ache, with  greater  heat  on  the  palsied  side.  If  the  obstruction  be  in 
the  left  middle  cerebral  or  its  branches,  which  is  more  common  than 
on  the  right  side,  aphasia  is  among  the  symptoms. 

The  hemiplegia  is  not  of  necessity  attended  with  loss  of  conscious- 
ness, or  this  is  slight  and  of  short  duration  ;  sometimes  giddiness  and 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  173 

incoherence  take  the  place  of  unconsciousness  ;  convulsions  are  not 
infrequent.  The  palsy  is  often  quickly  followed  by  gangrene  of  the 
extremities,  or  it  is  associated  with  disturbance  of  the  kidneys,  or 
with  enlargement  of  the  spleen  and  tenderness  in  the  splenic  region, 
due  to  emboli  in  these  organs.  Post-paralytic  phenomena,  athetoid 
movements  and  the  like,  are  more  common  after  softening  due  to 
vascular  occlusion  than  after  cerebral  hemorrhage.  Occlusion  of  the 
basilar  artery  may  give  rise  to  bilateral  palsy,  often  with  involvement 
of  the  fifth  and  facial  nerves,  with  impairment  of  articulation  and  deg- 
lutition ;  sometimes  with  ptosis,  with  contraction  or  dilatation  of  the 
pupils,  with  paralysis  of  the  third  and  fourth  nerves  ;  and  occasion- 
ally with  loss  of  conjugate  movement  of  the  eyes  and  with  hemianop- 
sia.    The  temperature  may  be  low  at  first  and  high  subsequently. 

The  clinical  distinction  between  cerebral  embolism  and  cerebral 
thrombosis  is  even  more  difficult  than  that  between  vascular  occlusion 
and  cerebral  hemorrhage  ;  it  may  be  impossible  during  life.  Throm- 
bosis from  disease  of  the  arteries  is  often  attended  with  premonitory 
symptoms,  such  as  headache,  vertigo,  numbness,  tingling,  weakness, 
impairment  of  memory,  and  psychic  changes.  In  any  case  the  diag- 
nosis depends  upon  the  recognition  of  the  conditions  that  favor  the 
occurrence  of  one  or  the  other,  and  upon  the  character  and  distribu- 
tion of  the  symptoms  present. 

Coagulation  of  the  blood  may  take  place  in  the  veins  and  sinuses 
of  the  brain  and  give  rise  to  grave  symptoms.  The  condition  may 
result  from  depressing  or  exhausting  disease  leading  to  weakness  of 
the  action  of  the  heart,  with  slowing  of  the  circulation  and  increased 
coagulability  of  the  blood  ;  or  from  adjacent  disease,  such  as  trauma- 
tism, caries,  meningitis,  tumor.  In  addition  to  such  cerebral  symptoms 
as  headache,  delirium,  vomiting,  convulsions,  coma,  palsy,  there  are 
present  oedema  of  the  scalp  and  forehead,  distention  of  the  communi- 
cating veins  on  the  surface,  and  epistaxis,  with  paralysis  of  individual 
cranial  nerves.  But  the  diagnosis  chiefly  depends  upon  a  recognition 
of  the  causative  factors  and  the  exclusion  of  other  conditions. 

Insensibility  from  Drink,  or  from  Narcotic  Poisons. — Both  these 
conditions  are  sometimes  very  difficult  to  distinguish  from  the  coma 
of  apoplexy.  In  intoxication  the  breath  has  a  strong  odor  of  liquor, 
and  alcohol  may  be  detected  in  the  urine,  points  which  would  be  con- 
clusive were  it  not  that  apoplexy  may  come  on  in  the  drunken  state. 
Then  the  drunken  man,  although  unconscious,  is  not  entirely  bereft  of 
all  power  of  motion, — he  is  certainly  not  paralyzed.  Moreover,  the 
pulse  is  not  slow,  it  is  frequent ;  the  pupils  are  generally  dilated ;  the 
eye  is  injected,  and  shows  no  lateral  deviation ;  there  is  often  violent 


174  MEDICAL  DIAGNOSIS. 

struggling,  and  the  symptoms  become  suddenly  much  ameliorated 
after  the  inhalation  of  ammonia.  In  narcotic  poisoning,  especially 
if  from  opium,  the  pupils  are  much  contracted,  and  we  are  likely 
to  encounter  a  gradual  intensification  of  the  coma.  The  patient, 
however,  unless  death  be  close  at  hand,  can  be  momentarily  roused 
from  his  deep  sleep  ;  and  his  calm,  slow  breathing  is  unlike  the  stertor 
of  apoplexy.  But  when  the  hemorrhage  has  taken  place  into  the 
pons  Varolii,  the  diagnosis  is  very  difficult,  especially  if  the  bleeding 
be  extensive,  for  then  we  are  apt  to  have  a  contraction  of  both  pupils, 
and  the  respiration  may  not  be  stertorous ;  nor  is  there  always  at 
first  paralysis.  A  symptom  of  great  diagnostic  significance,  too,  is 
the  occurrence  of  convulsions.  Still,  this  may  happen  in  opium 
poisoning,  and  is  not  very  rare  in  children. 

Nitrobenzole,  which  operates  as  a  narcotic  poison  in  vapor  as  well 
as  in  a  liquid  state,  may,  in  rapidly  fatal  cases,  produce  coma,  which 
may  be  mistaken  for  the  insensibility  of  apoplexy.  But  the  poison  is 
detected  by  its  strong  smell,  resembling  that  of  bitter  almonds.^ 
Poisoning  by  drinking  chloroform  gives  rise  to  many  of  the  symptoms 
of  apoplexy ;  it  is  discerned  by  the  odor  of  the  breath,  by  the  quick 
and  tumultuous  heart  action  that  accompanies  the  stertorous  breath- 
ing, by  the  relaxation  of  the  limbs,  by  the  deatlilike  aspect  of  the  face, 
by  the  widely  dilated  pupils,  and  by  the  complete  general  anaesthesia,^ 
Chloral  insensibility  is  often  preceded  by  vertigo  and  pains  in  the  legs 
and  arms,  and  is  attended  with  flushing  of  the  face,  injected  conjunc- 
tiva, a  weak  intermittent  heart ;  the  pulse  may,  however,  be  slow  and 
full.  Hydrocyanic  acid  poisoning  produces  profound  insensibility, 
often  attended  by  convulsions,  and  by  peculiar  breathing, — short  in- 
spiration with  labored,  prolonged  expiration.  The  breath  has  the 
characteristic  odor  of  prussic  acid. 

Urcemia. — The  strong  point  in  the  diagnosis  is  that  the  coma  is 
preceded  by  convulsions  ;  exceptional  instances  are  few  indeed.  An 
examination  of  the  urine  conduces,  of  course,  to  certainty ;  but,  for 
obvious  reasons,  it  cannot  always  aid  us  at  Once.  Moreover,  albu- 
min— not,  however,  in  large  amounts — may  occur  in  the  urine  after 
an  apoplectic  stroke,  and  after  convulsions  not  uraemic.  Puffy  eye- 
lids and  swollen  ankles,  coma  not  profound,  peculiar  stertor  seeming 
to  emanate  from  the  mouth,  and  pupils  normal  or  dilated  are  symp- 
toms that  belong  to  ursemic  coma.  Unilateral  convulsions  or  loss  of 
power  are  indicative  of  cerebral  mischief,  and  tell  against  uraemia. 

^  Taylor,  Guy's  Hospital  Reports,  vol.  x.,  3d  Series. 

'■^  As  in  the  case  reported  in  L' Union  Medicale,  Oct.  1864. 


DISEASES  OF  THE  BRAIN   AND  SPINAL   CORD.  175 

Diabetic  Coma. — Diabetic  coma  generally  begins,  not  abruptly,  but 
with  somnolency  whicti  passes  into  coma ;  it  is  often  preceded  by 
great  oppression,  and  is  attended  with  a  rapid,  weak  pulse,  but  not 
with  hemiplegia  or  other  local  palsies.  But  the  chief  distinction  is 
by  the  tests,  farther  on  described,  which  show  an  acid  intoxication. 

Syncope — Asphyxia. — The  loss  of  consciousness  in  either  of  these 
states  is  as  striking  as  in  apoplexy.  But  there  is  this  decided  differ- 
ence :  the  suspension  of  thought  and  of  volition  in  a  fainting-fit  is 
due  to  failure  of  the  circulation :  hence  the  pulse  is  hardly  or  not  at 
all  felt,  instead  of  being  full,  as  in  apoplexy.  Further,  the  pallor 
of  the  face,  the  quiet  or  sighing  respiration,  the  well-preserved  re- 
flexes, and  the  short  duration  of  the  syncope  mark  plainly  the  one 
affection  from  the  other.  And  with  reference  to  asphyxia,  the  turgid 
and  livid  face,  the  bluish  lip,  the  distressed  and  embarrassed  breath- 
ing preceding  the  convulsions,  and  the  loss  of  consciousness,  show 
clearly  that  the  disturbance  affects  primarily  the  lungs  and  not  the 
brain. 

Acute  Softening. — This  state  is  so  closely  connected  with  cerebral 
embolism  or  thrombosis  that  an  appreciation  of  the  history  of  the 
case,  and  the  causes  that  lead  to  occlusion  of  the  vessels,  tells  us  the 
meaning  of  the  cerebral  symptoms.  Rapid  softening,  too,  at  times 
happens  around  a  clot.  In  acute  softening  the  mental  phenomena 
are  always  obvious,  the  mind  is  much  more  obtuse  or  impaired  than 
it  is  after  the  shock  of  cerebral  hemorrhage  is  over.  Durand  Fardel  ^ 
regards  as  a  significant  sign  of  acute  softening  an  increased  secretion 
from  the  mouth  and  eye. 

Sudden  Extensive  Paralysis  without  Coma. — This  is  not  a  trait  of 
apoplexy,  but  rather  of  occlusion  of  the  large  vessels.  Sudden  exten- 
sive paralysis  without  coma  is  ordinarily  owing  to  the  breaking  down 
of  a  softened  brain,  most  apt  to  have  followed  this  occlusion ;  but  it 
may  be  due  to  hemorrhage  into  the  spinal  column.  Palsy  from  this 
source,  unlike  that  caused  by  cerebral  hemorrhage,  is  almost  invari- 
ably double-sided,  is  accompanied  by  severe  spinal  pain,  and,  if  the 
extravasation  have  taken  place  into  the  spinal  meninges,  by  tonic 
spasms,  like  those  of  tetanus. 

Protracted,  Sleep). — While  recovering  from  acute  diseases,  the  sick 
often  sleep  profoundly  and  for  a  long  time.  Yet  there  is  little  likeli- 
hood of  confounding  this  with  the  sleep  of  apoplexy ;  for  the  ante- 
cedent circumstances  reveal  the  meaning  of  this  restoration  of  nature. 
Sometimes,  however,  persons  sink  into  a  deep  and  prolonged  slumber 

^  Maladies  des  VieiUards. 


176  MEDICAL  DIAGNOSIS. 

without  any  previous  ailment.  Medical  literature  furnishes  a  num- 
ber of  such  instances.  In  one  recorded  by  Cousins/  the  tendency  to 
somnolency  lasted  for  years.  The  patient  frequently  slept  three,  and 
sometimes  five,  days  at  a  time.  When  he  awoke  he  was  well.  In  a 
case  which  I  saw  with  Dr.  Weir  Mitchell,^  the  slumberer  was  aroused 
out  of  her  trance  several  times  by  the  exciting  influence  of  electricity ; 
but  this  finally  lost  its  effect,  and  she  relapsed  into  a  sleep  from  which 
she  awoke  no  more.  These  cases  may  give  the  impression  of  apo- 
plexy, yet  they  do  not  resemble  it  strictly.  They  are  unlike  it  in  the 
gentle,  noiseless  breathing ;  in  the  feeble  pulse ;  in  the  occasional 
motion  of  the  body ;  and  in  the  protracted  unconsciousness.  Then 
generally  the  patient  can  be  roused  sufficiently  to  take  food.  Pro- 
longed somnolence  is  also  among  the  marked  symptoms  of  cerebral 
syphilis."  In  some  instances  the  disorder  shows  itself  in  a  constant 
tendency  to  fall  asleep  for  brief  periods  at  a  time.  One  patient 
I  had  slept  repeatedly  during  the  day,  while  on  her  feet,  about  five 
minutes  at  a  time.  She  could  be  awakened  by  strong  efforts.  The 
short  duration  of  the  spells  of  sleep,  and  the  absence  of  evidences  of 
hysteria  usual  in  trances,  distinguish  these  cases  of  nareolepsy  from 
trance.  The  narcolepsy  may  be,  however,  associated  with  catalepsy, 
and  there  are  cases  of  undoubtedly  hysterical  origin.  Such  a  case 
probably  was  the  one  of  the  lethargic  Irish  fasting  girl,  who  is  said  to 
have  existed  for  nearly  six  weeks  without  food ;  the  disorder  was 
ushered  in  by  hysterical  fits.*  The  recurrence  of  the  sleeping  fits, 
their  innocuousness,  and  the  absence  of  tremor  and  of  progressive 
emaciation  and  of  enlargement  of  the  cervical  glands  distinguish 
narcolepsy  from  the  dangerous  sleeping  sickness  of  Africa. 

Cerebral  Hysteria. — The  actual  similitude  and  the  points  of  con- 
trast between  this  curious  state  and  apoplexy  may  be  learned  from 
the  following  sketch : 

A  married  lady,  of  remarkably  impressionable  and  nervous  dis- 
position, had  been  for  many  months  suffering  from  amenorrhoea  and 
from  sluggish  action  of  the  bowels.  She  had  also  a  constant  cough, 
dependent  upon  tubercles  in  one  of  the  lungs.  She  had  been  in  very 
•bad  health,  but  by  the  beneficial  effects  of  a  sea-voyage,  her  symp- 

1  Medical  Times  and  Gazette,  April,  1863.  See  also  a  somewhat  similar  case, 
New  York  Medical  Journal,  Dec.  1867. 

^  Described  by  him.  Transactions  of  College  of  Physicians,  of  Philadelphia, 
1856. 

^  See  cases  in  Lecture  XVI.,  Buzzard  on  Diseases  of  the  Nervous  System,  1882. 

*  Lancet,  July  .15,  1893.  Another  sleeping  girl  is  mentioned,  ibid.,  July  29, 
1893. 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  177 

toms  were  much  amended.  She  began  to  gain  flesh,  and  to  take 
exercise  without  fatigue.  She  was,  however,  troubled  with  head- 
ache, and  with  pain  at  the  lower  part  of  the  abdomen.  On  one 
occasion  in  the  evening  I  ordered  her  some  cathartic  medicine ;  and 
in  the  morning  she  was  better  than  usual,  and  in  the  liveliest  spirits. 
A  few  hours  afterwards  I  was  sent  for,  and  found  her  insensible.  She 
had  complained  of  a  sudden,  sharp  cramp  near  the  umbilicus,  and 
had  then  ceased  to  speak.  She  remained  unconscious  for  about 
twelve  hours  ;  yet  not  wholly  so,  for  every  now  and  then  she  opened 
her  eyelids,  muttered  a  word  or  two,  a  pleasant  smile  flitted  over 
her  countenance,  but  she  soon  relapsed  into  deep  slumber.  Her 
thumbs  were  drawn  inward ;  she  had  occasional  convulsive  move- 
ments ;  the  breathing  was  rapid,  but  not  noisy ;  the  pulse  feeble, — at 
first  slow,  then  frequent ;  her  eyes  sc|uinted  in  the  most  decided 
manner.  Stimulants  and  antispasmodics  were  freely  given,  but  with- 
out much  benefit,  for  she  recovered  from  her  lethargy  only  with 
the  setting  in  of  the  most  violent  paroxysmal  pains  in  the  abdo- 
men, shooting  down  the  thigh,  and  accompanied  by  contractions  of 
the  muscles  and  by  exquisite  local  tenderness.  The  next  day,  with- 
out much  abatement  of  the  suffering,  she  was  perfectly  conscious ; 
but  still  she  had  an  internal  squint, — nay,  was  totally  blind,  and 
remained  so  for  two  days.  During  this  time  a  menstrual  discharge 
began,  which  in  part  relieved  the  abdominal  pain,  but  it  was  not 
fully  relieved  until  after  the  passage  of  large  fecal  masses.  It  is 
needless  to  point  out  how  this  display  of  hysteria  differed  from 
apoplexy. 

Aphasia. — The  faculty  of  speech  may  be  interfered  with  by  various 
lesions  of  the  brain  and  of  the  pons  and  the  medulla.  Of  these, 
some  cause  only  disturbance  of  articulation,  while  others  derange  the 
higher  speech  processes.  From  the  first  result  difficult  or  defective 
articulation,  dysarthria  or  anarthria ;  from  the  second,  the  group  of 
phenomena  included  in  the  designation  cqjhasia.  Though  this  is 
really  a  mere  symptom,  it  is  so  prominent  as  seemingly  to  constitute 
the  disorder.  By  aphasia  is  meant  loss  of  the  faculty  of  expression 
of  thought,  in  consequence  of  loss  either  of  the  faculty  of  speech,  or 
of  that  of  communicating  thought  by  writing  or  by  gestures.  The 
patient  may  be  deprived  of  the  ability  of  expressing  himself  in  one 
of  these  ways,  or  in  all.  The  loss  of  speech  is  the  most  common, 
and  is  apt  to  be  associated  with  a  very  decided  impairment  of  memory 
and  an  enfeeblement  of  intelligence.  The  disorder  may  be  tempo- 
rary, lasting  but  a  few  hours  or  some  days,  or  it  may  continue  for 
months  or  years.     During  its  course  the  affected  person  is  incapable 


178  MEDICAL   DIAGNOSIS. 

of  recalling  words  to  give  utterance  to  his  ideas  ;  or  if  he  can  recall 
the  words  to  the  mind,  and  thus  think,  he  cannot  express  them. 

Very  often  the  patient  has  but  a  few  words  at  his  control ;  he 
says  "  yps"  or  "  no"  for  everything ;  or  he  uses  wrong  words,  know- 
ing perhaps  that  they  are  wrong,  and  sometimes  only  those  of  a  pro- 
fane kind ;  or  he  confuses  merely  some  syllables  in  the  words  he 
employs ;  or  he  may  not  be  able  to  utter  an  intelligible  expression. 
Yet,  while  in  this  condition,  there  is  no  defect  in  the  tongue,  or  lips, 
or  palate,  to  account  for  the  inability  to  talk  ;  the  act  of  swallowing  is 
easily  performed ;  and  even  where  the  aphasia  is  complicated  with 
hemiplegia,  it  is  not  difficult  to  discern  that  the  imperfect  articulation 
and  thick  speech  that  may  attend  the  palsy  are  not  the  cause  of  the 
singular  disturbance  of  expression ;  a  disturbance  which  will  mostly 
show  itself  not  simply  by  the  failure  to  utter  words,  but  also  by  the 
inability  to  recollect  them  and  write  them  down.  Indeed,  it  is  neces- 
sary to  bear  in  mind  that,  while  these  states  may  coexist,  they  also 
may  be  present  separately.  Thus,  there  may  be  inability  to  express 
thought  in  speech, — motor  aphasia  or  word-mutism.  With  this  there 
is  often  associated  inability  to  express  thought  in  writing, — agraphia. 
Then,  there  may  be  inability  to  comprehend  spoken  language, — 
word-deafness ;  or  written  or  printed  language, — "  alexia."  Most 
patients  understand  perfectly  well  what  is  said  to  them ;  some  can 
read  to  themselves ;  and,  unless  the  general  intelligence  be  percepti- 
bly affected,  they  can  express  themselves  by  signs  and  gestures.  In 
some  cases  there  is  rather  loss  of  memory,  and  forgetfulness  and 
confusion,  and  perhaps  a  consequent  use  of  wrong  words  ;  but  when 
prompted  the  word  is  at  once  spoken.  Where  the  power  of  expres- 
sion only  is  lost,  but  the  perception  of  thought-symbols  is  still 
present,  the  term  "motor  aphasia"  is  used.  Where  the  latter  is 
lost,  it  is  customary  to  speak  of  the  affection  as  "  sensory  aphasia ;" 
word-deafness  and  alexia  are  forms  of  this.  Again,  there  are  cases 
in  which  words  and  ideas  remain,  but  in  which  the  power  of  form- 
ing correct  sentences  is  greatly  impaired,  or  is  lost.  This  has  been 
named  "  akataphasia"  or  paraphasia. 

Slips  of  the  tongue  are  by  no  means  always  to  be  regarded  as 
aphasia,  for  very  often  these  have  a  local  cause,  such  as  a  sore  tongue 
or  lip,  or  a  sharp  tooth  fretting  the  tongue,  producing  unusual  sensa- 
tions in  the  mouth.^ 

Aphasia  is  dependent  upon  disease  situated  in  the  frontal  convo- 
lutions, in  the  seat  of  articulate  language  in  the  posterior  part  of  the 

^  Ord,  St.  Thomas's  Hospital  Reports,  vol.  iv. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  179 

third  frontal  convolution  of  the  left  side  of  the  cerebrum.  This  ex- 
plains why  the  hemiplegia  which  may  accompany  aphasia  is  almost 
invariably  right-sided.  But  it  may  be  left-sided,  if  the  corresponding 
parts  of  the  right  hemisphere  have  become  the  main  centre  of  speech, 
as  happens  not  infrequently  in  left-handed  persons.^  It  has  been  fur- 
ther shown  that  the  disturbance  will  be  in  the  cortical  substance  of  the 
speech-centre,  of  the  auditory  centre,  or  of  the  visual  centre,  or  in  the 
association-fibres,  according  to  the  form  of  aphasia.  With  the  first, 
motor  aphasia  especially  results,  with  the  others,  sensory  aphasia. 

The  function  of  speech  is  subserved  through  sensory  and  motor 
processes.  The  former  have  to  do  with  the  reception  of  impressions 
from  without,  principally  through  hearing  and  sight,  and  the  centres 
for  these  are  in  right-handed  persons  respectively  in  the  first  temporal 
convolution  and  in  the  angular  gyrus  on  the  left  side ;  the  motor 
speech  processes  originate  in  Broca's  convolution.  In  disease  de- 
stroying the  latter  and  causing  motor  aphasia,  the  patient  understands, 
but  can  speak  but  few  words  or  syllables  ;  in  disease  affecting  the 
sensory  centres,  the  auditory  and  visual  appreciation  of  words  is  im- 
paired or  lost.  When  the  first  left  temporal  convolution  is  the  seat 
of  lesion,  "  auditory  aphasia"  or  "  word-deafness,"  with  loss  of  hear- 
ing in  the  opposite  ear,  results,  and  words  are  wrongly  used,  and 
speech  fails  to  convey  any  ideas.  The  words  are  heard  merely  as 
sounds.  The  patient  fails  to  recognize  his  mistakes  in  speech,  and  is 
unable  to  correctly  repeat  words  spoken  to  him.  Disease  of  the 
angular  gyrus  on  the  left  side  gives  rise  to  "  visual  aphasia,"  or  "  word- 
blindness,"  or  even  to  "  mind-blindness,"  the  patient  being  unable  to 
recognize  words  or  objects  through  vision.  There  thus  result  alexia 
and  perhaps  agraphia,  together  with  loss  of  vision  in  the  right  half  of 
the  visual  fields. 

Aphasia  may  be  due  to  functional  as  well  as  to  organic  disease. 
In  cases  of  aphasia  of  short  duration  and  without  palsy,  there  is  prob- 
ably merely  congestion ;  in  protracted  cases,  and  those  in  which  we 
find  persisting  hemiplegia,  a  large  clot,  or  softening,  or  abscess,  is  likely 
to  be  present ;  embolism  of  the  middle  cerebral  artery  on  the  left  side 
is  prone  to  be  the  cause  in  cases  that  are  associated  with  valvular  dis- 
ease of  the  heart  and  that  have  come  on  suddenly.  Thrombosis  from 
enfeebled  nutrition  will  explain  some  of  the  cases  of  aphasia  noticed 

^  The  speech-centre  is  not  invariably  situated  on  the  left  side  in  right-handed 
persons,  nor  on  the  right  in  left-handed  persons,  as  cases  reported  by  Wadham 
(St.  George's  Hosp.  Rep.,  1868,  iv.  245),  Dickinson  (Bastian,  Aphasia  and  other 
Speech-Defects,  1898,  p.  90),  and  CoUier  (Lancet,  March  25,  1899,  p.  824)  amply 
demonstrate.  ' 


180  MEDICAL  DIAGNOSIS. 

during  convalescence  from  grave  acute  maladies.  That  consequent 
upon  congestions  ends  in  more  or  less  rapid  recovery ;  in  the  other 
forms,  usually,  either  no  improvement  follows,  or  only  a  very  partial 
gain  of  words  takes  place.  Occasionally  we  meet  with  aphasia  in 
hysteria  or  in  epilepsy,  in  acute  infectious  diseases,  in  toxsemias,  and 
in  uraemia,  or  we  encounter  aphasia  intimately  connected  with  a  syph- 
ilitic cachexia,  and  dependent  most  probably  upon  disease  of  the  arte- 
ries. Transitory  aphasia  has  been  observed  in  the  course  of  pneu- 
monia. The  complication  usually  appears  towards  the  second  or,  third 
day  of  the  disease,  being  ordinarily  preceded  by  headache  and  vertigo, 
and  sometimes  by  numbness  and  tingling  on  the  right  side  of  the  body. 
It  may  set  in  abruptly,  without  loss  of  consciousness,  or  be  preceded 
by  an  apoplectiform  seizure.  There  may  be,  in  addition,  transient 
palsy  of  the  right  side  of  the  body.  The  manifestation  is  thought  to 
be  due  to  the  action  of  the  toxic  products  of  the  disease  process.^ 

Aphasia  may  become  manifest  subsequent  to  attacks  of  vertigo,  or 
to  a  paralytic  stroke  preceded  or  not  by  the  ordinary  signs  of  an  apo- 
plectic fit.  Under  these  circumstances  the  diagnosis  cannot  be  defi- 
nitely made  until  consciousness  has  returned,  and  we  have  an  oppor- 
tunity of  examining  the  state  of  the  mind,  and  of  the  tongue,  and  of 
the  muscles  concerned  in  articulation,  remembering  that  if  there  be 
merely  difficulty  in  articulation  the  case  is  not  one  of  aphasia. 

Sunstroke. — Persons  exposed  to  the  scorching  rays  of  the  sun 
in  midsummer  often  become  dizzy,  and  fall  to  the  ground  insensible  : 
they  have  had  a  sunstroke.  The  attack  either  takes  place  while  the 
patient  is  still  exposed  to  the  sun,  or,  in  rarer  instances,  he  reaches 
his  home  with  a  staggering  gait  and  a  suffused  face,  giddy,  faint,  suffer- 
ing from  a  dull,  oppressive  pain  in  the  head,  having  a  constant  desire 
to  micturate,  and  after  some  hours  becomes  unconscious.  However 
the  onset,  the  insensibility  which  occurs  is  generally  complete,  although 
it  may  be  so  but  for  a  few  minutes.  Associated  with  it  are  a  frequent 
pulse,  a  skin  harsh  and  warm  and  sometimes  very  hot  on  the  fore- 
head, shallow,  noisy  breathing,  difficulty  in  swallowing,  contracted  or, 
more  generally,  dilated  pupils,  and  relaxation  of  the  limbs.  Scanty 
urine,  delirium,  and  convulsions,  which  may  or  may  not  depend  on 
uraemia,  are  not  uncommon. 

When  we  contrast  these  symptoms  with  those  of  apoplexy,  we  find 
the  following  marks  of  distinction :  the  pulse  is  not  slow  and  full,  but 
frequent  and  often  feeble  ;  there  is  more  difficulty  in  deglutition,  but 
a  less  snoring  respiration ;  the  coma  does  not  ordinarily  remain  as 

^  Chantemesse,  Semaine  Medicale,  1893,  No.  73,  p.  582. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  igl 

complete  for  so  great  a  length  of  time,  for  soon  the  patient  may  be, 
temporarily  at  least,  roused  from  his  deep  sleep ;  and  no  hemiplegia, 
no  paralysis,  either  of  the  limbs  or  of  the  cheek,  occurs.  The  tem- 
perature of  the  body  is  very  high,  104°  to  109°,  and  not  below  the 
normal,  as  it  is  at  first  in  apoplexy.  The  after-symptoms,  too,  are 
different :  in  cerebral  hemorrhage,  paralysis  ;  in  sunstroke,  feebleness 
of  movement,  but  no  paralysis.  In  the  former,  no  marked,  persistent 
headache  ;  in  the  latter,  headache,  more  or  less  chronic,  always  aggra- 
vated by  walking  in  the  sun,  and  often  for  months  accompanied  by 
signs  of  an  exhausted  nervous  system,  and  in  some  instances  by  epi- 
leptic convulsions. 

The  question  with  regard  to  the  discrimination  of  these  morbid 
states  is  one  of  great  practical  value,  as  on  the  conclusion  arrived  at 
depends  our  therapeutic  action  ;  and  generally  it  is  readily  determined 
by  paying  attention  to  the  variance  in  the  symptoms  mentioned.  But 
it  must  be  confessed  that  we  sometimes  meet  with  ambiguous  cases, — 
cases  in  which  the  signs  of  nervous  exhaustion  produced  by  exposure 
to  heat  are  blended  with  those  of  cerebral  congestion  or  hemorrhage 
excited  by  the  same  cause,  and  in  which,  when  they  terminate  fatally, 
the  autopsy  shows  not  simply  a  changed  blood,  or  pulmonary  conges- 
tion, but  turgescence  of  the  cerebral  vessels,  or  an  extravasation.  It 
may  also  be  difficult  to  distinguish  between  sunstroke  and  acute  alco- 
holism, particularly  because  those  who  drink  freely  are  very  prone  to 
the  disease.  The  chief  distinguishing  trait  is  in  the  high  temperature 
of  sunstroke,  and  the  normal  or  lowered  temperature  of  alcoholism. 

The  remarks  just  made  refer  to  the  most  common  form  of  sun- 
stroke,— that  attended  with  more  or  less  sudden  loss  of  conscious- 
ness. But  there  are  cases  in  which  the  abnormal  manifestations 
come  on  -gradually,  and  in  which  the  patient  at  no  time  becomes  in- 
sensible. The  chief  symptoms  are  intense  headache,  nausea,  pros- 
tration, and  inability  to  perform  any  work  requiring  sustained  attention. 
All  these  signs  appear  after  protracted  exposure  to  the  sun ;  and  they 
mend  but  tardily.  In  truth,  in  the  slowly  developed  disorder,  -the 
subsequent  nervous  exhaustion  and  the  paroxysms  of  headache  are 
often  much  more  persistent  than  are  the  same  phenomena  when  they 
follow  what  seems  to  be  the  more  violent  form  of  the  malady.  Among 
the  sequelae  of  these  apparently  incomplete  attacks  are  irritability  of 
the  bladder,  incontinence  of  urine,  and  irregular  action  of  the  heart. 
But  nothing  is  as  striking  as  the  loss  of  mental  and  bodily  energy. 

The  symptoms  of  "insolatio,"  or  sunstroke,  may  be  induced  by 
prolonged  atmospheric  heat  while  the  patient  is  in-doors  and  not  ex- 
posed to  the  rays  of  the  sun.     Such  cases  of  heat-stroke  are  known 


182  MEDICAL  DIAGNOSIS. 

to  occur  in  Inclia  even  at  midnight.  They  may  be  preceded  by  a 
sense  of  extreme  weariness,  by  inability  to  sleep,  by  loss  of  appetite, 
by  constipation  and  frequent  micturition,  and  by  deficient  perspira- 
tion ;  or  the  signs  of  exhaustion,  followed  by  more  or  less  complete 
insensibility,  appear  without  distinct  prodromes.  Cases  of  the  kind 
under  consideration  may  or  may  not  show  an  increased  or  high  tem- 
perature ;  generally  they  do. 

Then,  again,  we  find  cases  of  heat  exhaustion^  often  seen  in  our 
hot  summers,  in  which  there  is  from  the  first  great  tendency  to  syn- 
cope ;  the  skin  is  pale,  cool,  and  moist,  the  temperature  not  increased, 
the  pulse  very  feeble,  the  pupils  dilated,  and  stimulants  freely  given 
rapidly  relieve  the  urgent  symptoms. 

The  nature  of  heat  exhaustion,  as  of  sunstroke,  is  obscure.  The 
latter  is  held  to  be  a  fever  which  is  dependent  upon  heat.^  Certain  it 
is  that  the  heat-centres  are  very  much  disturbed  in  the  afi'ection.  It 
has  also  been  suggested  that  sunstroke  is  an  infectious  disease,  due  to 
micro-organisms.  In  occasional  instances  menmgitis  rather  than  sun- 
stroke follows  exposure  to  the  sun,  and  we  find  the  ordinary  symptoms 
of  meningeal  inflammation. 

Catalepsy. — This  is  a  sudden  suspension  of  thought,  of  sensi- 
bility, and  of  voluntary  motion,  during  the  continuance  of  which  the 
muscles  become  rigid,  although  they  retain  the  exact  position  they 
happen  to  be  placed  in.  The  uncommon  complaint  occurs  in  parox- 
ysms, which  may  last  but  a  few  minutes  or  for  several  hours,  and 
during  which  the  most  complete  anaesthesia,  not  only  of  the  skin,  but 
also  of  the  deeper  tissues,  may  occur.^  Often  consciousness  is  lost, 
but  it  may  be  only  obscured.  Respiration  is  disordered,  the  circula- 
tion is  feeble,  reflex  action  is  abolished,  and  the  temperature  is 
lowered.  The  disorder  is  met  with  mainly  in  females,  especially  in 
hysterical  females,  and  may  alternate  with  outbreaks  of  hysteria. 
But  it  may  also  exist  in  the  male  sex,  and  be  in  either  hereditary. 
It  has  even  been  noticed  as  an  epidemic  in  localities  where  there  are 
many  families  closely  connected  by  intermarriage.^  Nervous  exhaus- 
tion or  sudden  alarm  predisposes  to  the  seizures,  which  at  times  recur 
periodically  and  last  from  a  few  minutes  to  a  few  hours. 

Catalepsy  may  be  mistaken  for  apoplexy,  or  even  for  death.  It 
differs  from  apoplexy  by  its  frequent  recurrence  :  and  further,  during 
an  attack  the  eyes  are  wide  open,  the  pupils,  although  dilated,  are 

^  H.  C.  Wood,  Thermic  Fever,  or  Sunstroke. 

^  As  in  the  case  reported  by  Lasegue,  Archives  Generales  de  Medecine.  tome  i., 
1864. 

^  Vogt,  Schmidt's  Jahrbiicher,  Bd.  cxx.  p.  301. 


DISEASES  OF  THE  BRAIN   AND   SPINAL   CORD.  183 

very  susceptible  to  light,  and  there  is  an  absence  of  stertorous  breath- 
ing as  well  as  of  the  characteristic  relaxation  of  the  muscles  or  of  the 
paralysis  of  apoplexy, — for  the  limbs  are  outstretched,  or  held  in 
every  conceivable  annoying  'or  painful  position ;  yet  as  soon  as  con- 
sciousness is  restored  their  movement  fully  returns.  The  pulse  is 
not  retarded ;  on  the  contrary,  although  feeble,  it  becomes  very 
frequent. 

The  perplexing  affection  varies  from  a  kindred  state,  ecstasy^  in 
this :  in  the  latter  the  loss  of  consciousness  is  not  complete ;  the 
patient  is  merely  insensible  to  external  objects,  because  he  is  intensely 
absorbed  in  some  vision  present  to  his  imagination,  or  in  the  contem- 
plation of  some  subject  to  him  of  all-engrossing  interest.  But  he  is 
not  statue-like ;  on  the  contrary,  his  countenance  is  animated  and 
earnest,  and  he  talks,  declaims,  sings. 

There  is  a  curious  form  of  the  disorder,  which  Sir  Thomas  Watson 
describes.  It  is  an  imperfect  kind  of  catalepsy,  called  daymare,  the 
affected  person  being  incapable  of  moving  or  speaking,  yet  cognizant 
of  all  that  goes  on.  These  seizures  of  temporary  deprivation  of  mus- 
cular power,  without  unconsciousness,  are  thought  to  depend  upon  a 
diseased  state  of  the  blood-vessels  of  the  brain. 

Feigned  catalepsy  may  be  distinguished  from  the  true  disease  by 
the  muscles  quickly  showing  signs  of  fatigue,  which  they  do  not  in 
real  catalepsy.  A  pressure-drum,  Charcot^  found,  fixed  at  the  ex- 
tremity of  the  outstretched  limb  in  a  person  who  feigns,  will  in  a  few 
minutes,  in  place  of  the  straight,  regular  line,  show  crooked,  very  un- 
dulating traces,  and  the  same  irregularity  is  seen  in  the  tracings  of  the 
pneumograph  applied  to  the  chest. 

Catalepsy  may  be  artificially  induced,  as  we  know  from  the  inter- 
esting experiments  on  hypnotism  which  of  late  years  have  been 
made.  Catalepsies  of  particular  groups  of  muscles,  or  partial  cata- 
lepsies^ can  also  be  artificially  excited. 

In  the  rare  condition  known  as  trance^  or  lethargy,  there  exists  a 
state  resembling  sleep,  from  which  the  person  can  be  roused  with 
difficulty,  if  at  all.  It  is  principally  associated  with  hysteria,  although 
it  has  been  observed  as  a  result  of  excessive  mental  application  and 
after  exhausting  disease.  The  patient  is  usually  pallid.  The  ex- 
tremities are,  as  a  rule,  relaxed,,  although  they  may  be  rigid  for  a 
time,  and  there  may  even  be  convulsions.  The  eyelids  are  closed 
and  the  eyes  turned  upward  and  to  one  side  ;  the  pupils  vary  in  size, 
but  react  to  light.     Reflex  action  is  usually  lowered.     Respiration  and 


^  Third  volume  of  Clinical  Lectures,  1889. 


184  MEDIC Ali  DIAGNOSIS. 

circulation  are  greatly  enfeebled ;  the  peripheral  temperature  is  sub- 
normal. An  attack  lasts  from  a  few  hours  to  weeks.  Cases  in  which 
it  occurred  without  any  obvious  previous  ailment  have  been  men- 
tioned while  discussing  protracted  sleep.  In  narcolepsy  there  occur 
sudden  short  periods  of  day  sleep,  from  which,  however,  the  indi- 
vidual can  be  roused.  These  may  recur  spontaneously,  or  be  induced 
by  peripheral  impressions  ;  at  times  we  find  the  condition  in  diabetic 
or  gouty  patients. 

The  affection  described  as  African  lethargy^  or  sleeping  sickness, 
attacks  negroes,  principally  on  the  west  coast  of  Africa,  and  is  char- 
acterized by  somnolence  of  progressive  degree,  usually  leading  to  great 
emaciation  and  to  a  fatal  termination.  Among  its  marked  symptoms 
are  drooping  of  the  upper  eyelid,  puffiness  of  face,  muscular  tremor, 
itching,  papular  eruptions,  a  feeling  of  coldness  even  when  lying  in 
the  broiling  sun,  and  enlargement  of  the  cervical,  parotid,  and  sub- 
maxillary glands.  The  disease  is  thought  by  some  to  be  due  to  the 
presence  in  the  blood  of  the  Filaria  sanguinis  ;  by  others  to  a  lesion 
of  the  pituitary  body.  It  resembles  beriberi,  but  does  not  show  the 
hypersesthesia  of  muscles,  the  abolished  knee-jerk,  the  muscular 
atrophy  this  presents. 

Diseases  marked  by  Convulsions  or  Spasms. 

Epilepsy. — Epilepsy  is  a  disease  the  chief  manifestation  of  which 
consists  in  recurring  attacks  of  sudden  loss  of  consciousness,  attended 
with  convulsive  movements.  The  patient  falls  to  the  ground,  without 
thought,  without  feeling,  without  the  power  of  voluntary  motion. 
He  utters  often  a  short,  piercing  cry,  then  a  fearful  struggle  begins. 
The  legs  are  stiff,  and  turned  inward ;  the  head  is  tossed  backward, 
or  from  side  to  side  ;  the  mouth  is  distorted,  the  lips  are  covered 
with  foam ;  the  arms  are  outstretched  and  rigid,  or  thrown  about 
with  great  force  ;  the  eyelids  are  half  closed ;  the  teeth  are  ground 
together,  and  the  tongue  is  thrust  between  them,  and  often  severely 
bitten.  The  face  is  often  pale  at  the  outset,  but  with  the  continuance 
of  the  tonic  spasm  the  aspect  becomes  cyanotic.  In  a  short  while 
the  rigidity  gives  way  to  clonic  convulsions  and  the  whole  body  may 
be  agitated  by  violent  movements,  which  may  involve  one  side  in 
greater  degree  than  the  other,  and  during  which  sometimes  urine  is 
passed.  Gradually  the  convulsive  movements  become  less  violent 
and  cease  altogether,  and  the  patient  passes  into  a  deep  sleep,  from 
which  he  awakes  fatigued  and  exhausted,  and  dull  in  intellect.  But 
these  symptoms  disappear,  and  he  returns  to  his  normal  state  of  health. 
The  attack  generally  occupies  only  a  few  minutes.     In  some  cases, 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  185 

however,  the  patient  scarcely  emerges  from  one  attack  before  he  enters 
upon  another.  This  condition  is  known  as  the  status  ejnleptiGus,  and 
it  may  be  kept  up  for  hours. 

Yet  every  paroxysm  does  not  present  the  same  phenomena,  or 
run  the  same  definite  course.  In  many  the  attack  is  preceded  by 
strange  sensations  ;  by  a  peculiar  train  of  thought ;  by  retelling ;  by 
the  feeling  of  a  puff  of  air  ascending  from  the  extremities  to  the 
head.  This  ''  aura  epileptica"  is,  however,  far  from  constant. 
Moreover,  it  may  exist  and  hardly  be  perceived :  it  may  be  an  unfelt 
irritation  starting  from  some  peripheral  nerve  in  any  part  of  the  skin, 
or  from  some  organ  not  deeply  seated,  as  the  testicle,  and  its  point  of 
departure  may  be  detected  by  observing,  during  the  fit,  in  what 
neighborhood  the  first,  or  the  most  violent,  or  the  most  prolonged 
contractions  occur.  In  very  rare  instances  sudden  spasms  of  the  face 
and  chest  occur,  with  arrest  of  respiration,  and  with  a  subsequent 
clonic  convulsion,  yet  with  so  little  unconsciousness  that  it  remains 
doubtful  whether  it  has  happened  at  all. 

Some  seizures  are  very  light, — a  transient  suspension  of  conscious- 
ness, a  slight  twitching  of  some  of  the  muscles,  a  fixed  gaze,  perhaps 
a  decided  impression  of  vertigo,  and  all  is  over.  These  abortive  fits, 
the  petit  mal,  or  minor  attacks,  are  very  apt  to  precede  by  some  days 
a  severe  attack,  or  several  of  them  may  take  the  place  of  the  more 
turbulent  form  of  the  disorder.  And  they,  like  the  graver  epileptic 
convulsion,  may  present  strange  irregularities.  They  may  manifest 
themselves,  for  instance,  only  in  bursts  of  unmeaning  laughter;^  or 
intellectual  derangement  replaces  the  ordinary  convulsive  attack  ;  ^  or 
there  is  mental  wandering,  with  disposition  to  commit  acts  of  violence. 
The  attacks  of  epilepsy  which  are  chiefly  characterized  by  vertigo 
are  distinguished  from  all  other  forms  of  vertigo  by  the  loss  of  con- 
sciousness, however  slight,  they  also  present,  and  by  the  absence  of 
any  giddiness  in  the  intervals.  In  nocturnal  epilepsy  ecchymoses  on 
the  face,  conjunctival  extravasations,  a  severe  headache  on  awaken- 
ing, and  a  sore  tongue,  may  indicate  what  has  happened  in  the  night. 

The  epileptic  paroxysm  does  not  always  pass  off  without  leaving 
some  trace  of  the  profound  disturbance  it  has  occasioned.  It  may 
be  followed  by  hemiplegia.  Whether  this  be  due,  as  Hughlings 
Jackson^  asserts,  to  exhaustion  of  the  nerve-centres  following  the 
excessive   discharge   of   nerve-force   bringing  about  the   convulsion, 

^  George  Paget,  British  Medical  Journal,  Feb.  1869. 
^  Thorne,  on  Masked  Epilepsy,  St.  Bartholomew's  Hosp.  Rep.,  vol.  vi. 
3  After-Effects  of  Epileptic  Discharges,  West  Riding  Reports,  1876. 

12 


Igg  MEDICAL  DIAGNOSIS. 

4 

it  is  certain  that  the  palsy  is  very  transient.  Another  sequel  of  the 
attack  is  aphasia  ;  another,  loss  of  voice  ;  another,  abdominal  tender- 
ness. As  regards  palsy,  however,  we  must  remember  that  epileptic 
fits  may  follow  hemiplegia  due  to  a  vascular  lesion,  so-called  post- 
hemiplegic epilepsy. 

In  the  intervals  between  the  seizures  the  patient  is  not  in  reality 
well.  His  temper  is  irritable,  and  his  mental  faculties  slowly  but  cer- 
tainly deteriorate.  The  loss  of  memory,  particularly,  is  very  marked  ; 
and  dementia  is  not  an  unusual  complication  of  long  contmued 
epilepsy.  In  some  epileptics  there  is  much  excitement  or  a  curious 
mental  state  preceding  the  seizures,  or  a  violent  and  dangerous  mania 
may  follow  them.  Again,  as  I  have  noted  in  common  with  several 
observers,  a  temporary  albuminuria  is  not  unfrequently  met  with  at 
the  termination  of  the  paroxysm. 

True  epilepsy  is  probably  owing  to  functional  or  nutritional 
changes  in  the  cortex  of  the  brain,  giving  rise  to  excessive  activity  of 
nerve-cells  leading  to  periodic  discharges  of  nerve-force.  Its  most 
potent  cause  certainly  is  hereditary  predisposition.  Convulsions  due 
to  reflex  irritation,  to  organic  brain  disease,  and  to  toxic  blood-states 
may  result  in  true  epilepsy.  It  is  thus  that  the  malady  originates  in 
injuries  of  nerves,  in  diseases  of  the  skin,  of  the  stomach  and  intes- 
tines, and  of  the  uterus,  in  the  irritation  of  worms,  or  in  consequence 
of  congenital  phimosis,^  or  of  chronic  nasal  catarrh.^  Now,  it  is  very 
important  to  discriminate  between  true  epilepsy  and  convulsions  of 
eccentric  origin;  and  to  arrive  at  a  conclusion  is  possible  only  by  a 
thorough  examination  of  all  the  constitutional  symptoms,  and  by 
ascertaining  the  starting-point  and  tracing  the  course  of  the  aura. 
The  cases  in  which  the  aura  is  interrupted  and  the  paroxysm  arrested 
by  a  ligature  are  well  known.  Nothnagel  cites  an  instance  in  which 
the  aura  began  with  peculiar  sensations  in  the  stomach,  and  the 
attack  was  stopped  by  swallowing  table-salt.  Convulsions  may 
further  be  symptomatic  of  a  cerebral  disorder, — such  as  a  tumor, 
cysticerci  lodged  in  the  organ,  a  syphilitic  affection  of  the  membranes, 
or  a  disturbance  of  the  brain  produced  by  disease  of  the  skull-cap, — 
in  fact,  of  any  disease-process  affecting  the  cortex  of  the  brain ;  or  it 
may  be  due  to  watery  blood,  or  vitiated  blood  full  of  abnormal  in- 
gredients, as  in  diseases  of  the  kidneys,  acting  injuriously  on  the 
nutrition  of  the  cerebral  texture.  During  the  paroxysm  it  is  im- 
possible to  determine  the  character  of  the  convulsions  ;   but  in  the 


1  Althaus,  Lancet,  Feb.  1867. 

2  Cases  collected  by  Salinger,  Polyclinic,  June,  1887. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  187 

interval  we  may  often  do  so  by  close  attention  to  the  history  of  the 
case,  and  by  noting  whether  the  patient  enjoys  the  usual  health  of 
epileptic  subjects,  or  presents  signs  of  a  chronic  cerebral  disorder, 
especially  steady  headache,  palsies  of  cranial  nerves,  optic  neuritis, 
vomiting.  Romberg  tells  us  that  where  affections  of  the  bones  of  the 
head  lie  at  the  root  of  the  complaint,  the  fits  are  readily  induced  by 
pressure  upon  the  skull.  Convulsions  are  often  found  in  connection 
with  ear  disease,  and  especially  with  purulent  otitis.^  In  those  who 
inherit  syphilis  idiopathic  epilepsy  may  happen. 

Limited  convulsive  seizures  are  connected  with  disease  of  special 
convolutions ;  and  if  we  have  a  convulsion  which  is  limited,  either  a 
tonic  or  a  clonic  spasm  of  a  group  of  muscles,  we  may  from  this  mono- 
spasm diagnosticate  an  irritative  lesion  in  the  motor  centre  presiding 
over  the  disturbed  part,  though  in  the  hemisphere  opposite  to  the 
spasm.  The  irritative  lesion  is  usually  a  meningo-encephalitis.  The 
spasm  most  frequently  originates  in  the  hand,  but  we  may  also  find 
it  limited  to  a  group  of  muscles  in  the  face,  or  in  the  leg.  At  first 
there  is  no  loss  of  consciousness  during  the  seizures,  but  as  the 
spasms  spread  and  become  unilateral,  consciousness  is  lost.  Convul- 
sions due  to  syphilitic  diseases  are,  for  the  most  part,  of  the  kind  just 
described,  and  are  the  chief  form  of  the  cortical  or  so-called  Jackso- 
nian  epilepsy.  In  mashed  epilepsy  there  is  often  an  epileptic  vertigo, 
with  loss  of  consciousness  and  with  twitching  of  some  muscles,  but 
the  patient  does  not  fall. 

Much  has  been  said  of  the  distinction  between  epilepsy  and  convul- 
,sions.  Now,  as  regards  the  seizure  itself,  there  is  no  appreciable  dif- 
ference :  the  only  diversity  consists  in  the  recurrence  of  the  attack  after 
intervals  of  comparative  health,  and  in  the  non-existence  of  any  dis- 
turbance from  which  convulsions  are  likely  to  arise,  such  as  reflex 
irritation,  organic  brain  disease,  or  a  toxic  blood-state.  In  young 
children  the  diagnosis  may  be  a  difficult  matter ;  but  the  fits  of  epi- 
lepsy, very  rare  in  them,  are  distinguishable  by  the  dulness  of  intel- 
lect, and  the  slow  mental  and  bodily  development,  observable  in  the 
intervals. 

The  diseases  which  are  most  apt  to  be  confounded  with  epilepsy 
are  hysteria  and  apojdexy.  The  former — like  all  the  rest  of  the  group 
now  under  discussion,  like  chorea,  like  tetanus,  like  hydrophobia— is 
discriminated  by  the  absence  of  that  perfect  suspension  of  conscious- 
ness that  takes  place  in  epileptic  seizures  ;  and  there  are  other  marks 
of  distinction,  to  which  we  shall  presently  refer.     In  apoplexy,  as  in 

^  Ormerod,  Brain,  April,  1883. 


188  MEDICAL  DIAGNOSIS. 

epilepsy,  we  meet  with  loss  of  consciousness,  sometimes  with  con- 
vulsions. But  these  are,  on  the  whole,  rare,  and  coma  precedes  and 
does  not  follow  them,  as  happens  in  epilepsy.  Then,  stertorous 
breathing  and  a  slow,  full  pulse  are  not  observed  in  epilepsy.  Epi- 
leptic patients  bite  their  tongues ;  this  does  not  occur  in  apoplexy. 
In  epilepsy  the  paroxysm  seldom  lasts  longer  than  from  ten  to  fifteen 
minutes  before  consciousness  returns  and  before  the  convulsions 
cease ;  in  apoplexy  the  insensibility  is  of  much  longer  duration. 
Epilepsy  is  not  usually  followed  by  paralysis  ;  apoplexy  is  commonly. 

There  is  sometimes  a  close  resemblance  between  syncope  and 
abortive  epilepsy,  petit  mal.  But  they  occur  under  widely  different 
conditions  ;  and  the  loss  as  well  as  the  return  of  consciousness  is  less 
abrupt  in  the  one  than  in  the  other. 

Epilepsy  is  at  iiraes  feigned ;  yet  impostors  cannot  feign  it  com- 
pletely. They  may  bite  their  tongue  ;  they  may  imitate  the  stertor, 
the  foam  at  the  mouth,  the  convulsions,  the  thumb  drawn  inward 
towards  the  palm,  the  confused  air  on  awakening ;  they  may  simulate, 
although  they  rarely  do  so,  the  indifference  to  pain ;  yet  there  is  one 
feature  of  the  real  attack  they  cannot  copy, — the  insensibility  of  the 
iris.  No  matter  how  skilful  the  dissembler,  his  pupils  must  contract 
when  exposed  to  a  strong  light,  they  must  dilate  when  the  stimulus  is 
withdrawn.  Unfortunately,  there  are  several  difficulties  in  making 
this  test  an  absolute  one.  In  the  first  place,  the  pupils,  during  a  fit 
cannot  be  always  readily  observed.  In  the  second  place,  not  in  every 
case  of  epilepsy  are  they  perfectly  immovable ;  in  some,  though  slug- 
gish, they  react  to  light.  Again,  as  proved  by  Keen,  violent  muscular 
motion  instantly  dilates  the  pupil,  and  so  long  as  the  movement  con- 
tinues, so  long  will  the  iris  act  sluggishly,  even  when  exposed  to  a 
bright  light.  Thus,  muscular  spasms  alone,  even  when  simulated, 
may  cause  the  pupils  to  be  dilated  and  inactive.  A  test  more  gen- 
erally useful  is  the  administration  of  ether.  When  given  to  an  epi- 
leptic, its  first  effect  is  to  increase  the  violence  of  the  spasm,  but 
eventually  the  patient  passes  into  the  deep  sleep  produced  by  ether, 
without  any  of  the  prior  cerebral  excitement ;  while  in  the  malingerer 
this  manifests  itself  by  talking  and  laughing, — in  fact,  in  the  usual  way.^ 

Chorea. — This  spasmodic  affection  is  chiefly  met  with  in  young 
persons,  especially  in  girls  approaching  the  age  of  puberty.  It  is 
characterized  by  irregular  clonic  spasms  of  groups  of  muscles  under 
the  influence  of  the  will,  and  mainly  of  those  on  one  side  of  the 
body,  together  with  muscular  incoordination.     But  the  patient  is  not 

^  Keen,  Mitchell,  and  Morehouse,  Amer.  Journ.  Med.  Sci.,  Oct.  1864. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  189 

deprived  of  consciousness  and  of  all  power  of  voluntary  motion.  He 
knows  what  he  is  about,  and  can  in  part  execute  the  movements  he 
undertakes ;  yet  his  limbs  are  not  completely  under  his  control. 
They  obey  only  his  general  directions,  but  not  entirely,  or  at  once  ; 
for  the  muscles  jerk  and  pull  as  seem  to  them  best,  taking  no  heed 
of  the  time  or  the  manner  in  which  the  will  wishes  any  movement 
executed.  In  some  cases  the  muscles  of  deglutition,  of  respiration, 
and  of  articulation  become  implicated  ;  and  difficulty  in  swallowing,  in 
breathing,  and  in  speaking  occurs.  A  dilated  pupil,  too,  acting  slug- 
gishly in  response  to  light,  may  be  met  with  among  the  phenomena  of 
the  malady.  Often  there  are  mental  irritability  and  dulness  of  intellect. 
The  urine  contains  urea  and  phosphates  in  excess. 

Chorea  is  essentially  a  functional  disorder  of  the  nervous  centres, 
especially  of  the  cells  of  the  cerebral  cortex.  In  a  large  number  of 
persons  the  malady  is  called  into  existence  by  an  irritation  of  periph- 
eral portions  of  the  nervous  system.  Thus,  a  blow,  a  wound  of  a 
nerve,  disorders  of  the  uterus,  painful  menstruation,  pregnancy,  eye- 
strain, or  gastric  or  intestinal  affections  may  act  as  the  exciting  cause 
of  the  perverted  muscular  movements.  In  cases  due  to  organic 
causes,  endocarditis  or  plugging  of  the  vessels  leading  to  the  corpus 
striatum  is  a  common  lesion,  one-sided  embolism  giving  rise  to  one- 
sided chorea.^  The  association  with  vegetations  on  the  valves  is  in 
fatal  cases  certainly  very  frequent.^  It  has,  indeed,  been  suggested  that 
the  wild,  maniacal  delirium,  with  subsequent  rapid  emaciation,  which 
we  meet  with  in  some  instances  of  chorea,  has  its  origin  in  embolism.^ 

Chorea  may  be  produced  by  strong  mental  emotion,  especially  by 
fright.  It  may  follow  scarlet  fever,  but  it  is  more  often  the  sequence 
of  rheumatic  fever  or  arises  from  the  same  diathesis  that  attends  or 
occasions  rheumatism.  Yet  this  is  not,  as  some  have  alleged,  its  only 
cause  ;  for  in  a  number  of  persons  affected  with  chorea  we  fail  to 
detect  any  proof  of  a  rheumatic  diathesis.  Still,  the  greatest  preva- 
lence of  chorea  in  the  spring  of  the  year  coincides,  as  Morris  J.  Lewis  * 
has  shown,  with  the  greatest  prevalence  of  rheumatism.  The  action 
of  special  toxic  substances  on  the  brain  is  held  by  several  to  be  the 
ultimate  cause.  As  regards  the  cardiac  complication,  the  presence  of 
which  is  chiefly  deduced  from  the  existence  of  a  murmur,  the  infer- . 
ence  drawn  of  this  being  due  to  "organic  disease, — to  endocarditis, — 

^  Hughlings  Jackson,  London  Hospital  Reports,  vol.  ii.,  and  Edinburgh  Medical 
Journal,  Oct.  1868. 

^  Ogle,  British  and  Foreign  Medico-Chirurgical  Review,  1868. 

^Tuckvf ell,  ibid.,  Oct.  1867. 

*Amer.  Journ.  Med.  Sci.,  Sept.  1892,  p.  251. 


190  MEDICAL  DIAGNOSIS. 

is  not  always  accurate ;  for  the  murmur  is  often  owing  to  ansemia,  or 
dependent  upon  spasmodic  action  of  the  papillary  muscles, — the  same 
spasmodic  action  that  is  seen  in  the  striated  muscles  of  the  face  and  of 
the  extremities. 

The  disease  is  rarely  fatal :  but  its  duration  is  very  variable ;  for, 
although  it  may  be  acute,  lasting  for  six  weeks  or  more,  it  may  con- 
tinue for  months,  even  for  years,  and  relapses  are  frequent.  There 
are  in  chronic  cases  no  attending  cerebral  symptoms,  yet  the  mental 
faculties  are  not  in  a  perfectly  healthy  state.  The  intellect  of  a 
choreic  child  develops  slowly,  and  is  enfeebled  while  the  disorder 
lasts.  In  some  cases  paralysis  supervenes  ;  but  it  is  not  permanent,  nor, 
indeed,  of  long  duration.  But  those  who  have  been  choreic  remain 
subject  to  nervous  disorders;  and  I* have  known  several  instances 
in  which  the  complaint  has  been,  in  after  years,  followed  by  epilepsy. 

A  chronic  progressive  form  of  chorea  sometimes  develops  late  in 
life,  mth,  in  many  instances,  a  history  of  hereclitarj^  transmission. 
The  movements  in  this  Huntington's  chorea  usually  appear  first  in 
the  face  and  upper  extremities,  and  graduahy  extend,  and  there  is 
disturbance  of  speech.  In  the  hereditary  cases  mental  changes  are 
common  and  sometimes  pronounced,  and  gradual  dementia  is  ob- 
served. In  some  parts  of  Italy  there  has  been  noticed  an  affection 
characterized  by  sudden,  shock-like  muscular  contractions,  with  pro- 
gressive palsy  and  wasting,  and  known  as  electrical  chorea.  Of  its 
nature  and  cause  we  have  no  definite  knowledge. 

So-called  hysterical  chorea  consists  in  general  spasmodic  movements 
occurring  in  hysterical  subjects,  but  the  movements  are  far  more  regu- 
lar and  rhythmical  than  those  of  true  chorea,  and  are  usually  deliberate 
and  of  wide  range. 

The  diagnosis  of  chorea  is  generally  easy.  The  peculiar  habit 
some  children  or  even  older  persons  get  into  of  winking,  or  jerking 
the  head,  or  of  making  other  strange  movements,  the  "  habit-chorea" 
or  "habit-spasm,"  as  it  has  been  called,  is  really  a  form  of  spasmodic 
tic,  and  is  distinguished  by  its  gradual  development  and  its  limitation 
to  a  single  muscle,  or  group  of  muscles,  or  of  associated  muscles. 
This  habit-spasm  is  not  infrequently  of  reflex  origin,  as  from  the  teeth 
or  from  eye-strain,  but  cases  occur  to  which  no  cause  can  be  assigned. 
Chorea  with  loss  of  power  on  one  side,  "  paralytic  chorea,"  is  recog- 
nized in  children  by  the  occasional  choreic  movements,  and  by  the  loss 
of  power  which  happens  gradually. 

Chorea  from  eye-strain  is,  as  a  ready  test,  discriminated  by  using 
atropine.  Dr.  Hansell  employed  this  in  many  cases  at  my  clinic  with 
quick  results.      Atropine  paralyzes  the   ciliary  muscle :    no  effort  of 


DISEASES  OF  THE  BRAIN  AND   SPINAL   CORD.  191 

accommodation  can  then  be  made  ;  therefore  muscular  twitching,  as 
well  as  headache  or  other  functional  disturbances  from  disordered 
accommodation,  must  cease  after  an  interval  of  time  long  enough  to 
break  up  the  habit ;  chorea  from  constitutional  causes  will,  of  course, 
be  unaffected  by  atropine  or  other  paralysis  of  the  ciliary  muscle. 

Chorea  differs  from  the  spasms  of  acute  cerebixd  disease  by  the 
absence  of  fever,  of  delirium,  and  of  coma,  though  we  must  bear  in 
mind  that  we  sometimes  have  elevation  of  temperature  and  mania  in 
the  chorea  of  pregnancy  ;  from  epilei^sy^  by  its  being  continuous,  by 
the  non-existence  of  unconsciousness,  and  by  the  rarity  with  which 
the  muscles  jerk  at  a  time  when  epileptic  convulsions  are  frequent, — 
at  night ;  from  tetanus  it  is  chiefly  distinguished  by  not  exhibiting  tonic 
spasm.  Paralysis  agitans  is,  like  chorea,  attended  with  disturbed 
muscular  movements.  But  we  find  weakness  of  the  muscles  and 
persistent  tremor  rather  than  spasmodic  contraction  and  want  of  con- 
trol over  muscular  motion.  Then  the  history  of  the  case,  and  the 
signs  of  general  decay  associated  with  the  trembling,  clearly  distin- 
guish paralysis  agitans.  In  cerebro-sjnnal  sclerosis,  the  scanning 
speech,  the  increased  patellar  tendon-reflex,  the  nystagmus,  the  occur- 
rence of  the  jerks  only  when  the  muscles  are  put  into  motion,  are 
most  significant.  Both  affections,  too,  are  encountered  in  persons 
older  than  are  generally  subject  to  chorea ;  especially  in  paralysis 
agitans.  Multiple  sclerosis  happens,  however,  also  in  children,  and 
we  meet  with  cases  of  paralysis  agitans  affiliated  to  chorea ;  like  it, 
too,  originating  in  fright.  But  they  differ  in  the  motions  repeating 
themselves  rhythmically  and  symmetrically  on  the  two  sides  of  the 
body,^  and  in  presenting  nothing  of  the  irregular  and  rapidly  changing 
character  of  the  true  choreic  movements. 

Convulsive  tremor,  a  paroxysmal  affection  in  which  severe  muscu- 
lar tremor  arises  several  times  in  a  day,  differs  from  chorea  in  not 
being  continuous,  as  it  occurs  in  attacks  lasting  from  fifteen  to  twenty 
minutes,  and  passing  off  gradually.  The  unrestrainable  tremor  affects 
the  face,  the  arms,  and  the  trunk,  but  not  the  lower  extremities,  and 
is  associated  with  increased  sensibility  of  the  skin  of  the  disturbed 
parts.  Clonic  spasms  occurring  as  sudden  contractions  or  shocks, 
and  affecting  pre-eminently  the  upper  part  of  the  limbs,  have  been 
delineated  by  Friedreich  as  myoclonus  multiplex ;  the  muscular  frrita- 
bility  is  much  increased. 

In  athetosis,  the  condition  descrDDed  by  Hammond,  there  is  con- 
stantly recurring  mobile  spasm  of  the  fingers  and  toes,  Avith  inability 

^  As  in  the  case  recorded  by  Sanders,  Edin.  Med.  Journ.,  May,  1865. 


192  MEDICAL  DIAGNOSIS. 

to  retain  them  in  any  position  in  which  they  may  have  been  placed. 
Great  tendency  to  distortion  exists  in  the  spasm,  and  we  find,  on  the 
whole,  much  resemblance  to  localized  chorea.  But  headache,  vertigo, 
slowness  of  speech  and  of  thought,  numbness  of  the  affected  side, 
and  pains  in  the  parts  which  are  the  seat  of  mobile  spasms,  give  us 
a  very  different  clinical  picture  from  chorea.  During  the  spasm  the 
fingers  may  be  spread  wide  apart,  giving  the  hand  a  characteristic 
appearance.  Athetosis  is  most  common  in  hemiplegics,  especially  in 
the  cerebral  hemiplegia  of  childhood,  and  coexists  with  contractures. 
It  is  supposed  to  be  due  to  disease  of  a  cortical  motor  centre.  It  has 
been  observed  to  be  bilateral  in  idiotic  children.  Similar  to  it  is  the 
mobile  spasm  that  may  be  noticed  in  palsied  limbs,  the  post-hemiplegic 
chorea.     But  here  there  is  an  admixture  of  tremulous  movements. 

Facial  spasm  differs  from  the  spasmodic  contractions  of  chorea  in 
being  always  of  equal  intensity,  and  in  the  grimaces  being  strictly 
confined  to  the  face,  manifesting  themselves  in  the  same  group  of 
muscles,  and  generally  existing  only  on  one  side  of  the  face.  Many 
cases  of  facial  spasm  are  due  to  errors  of  refii'action  ;  in  others  it  is  the 
result  of  cortical  disturbance  or  disease,  or  due  to  irritation  of  the  fila- 
ments of  the  fifth  nerve  in  the  lachrymo-nasal  canal.  The  spasm  may 
be  also  of  remote  reflex  origin,  as  from  disorders  of  the  uterus.  There 
are  also  cases  apparently  idiopathic.  In  convulsive  tic^  as  described  by 
the  French,  the  facial  spasm  is  combined  with  signs  of  hysteria  and 
with  mental  changes. 

TFnfers'  cramps  an  affection  in  which  every  attempt  at  writing  at 
once  produces  spasmodic  action  of  the  muscles  of  those  fingers  that 
are  brought  into  play,  is  separated  from  chorea  by  its  occurrence  m 
individuals  who  have  strained  their  muscles  in  using  a  pen  continu- 
ously and  rapidly ;  by  the  almost  instant  cessation  of  the  spasm  when 
the  afflicted  person  ceases  to  write ;  and  by  the  ease  with  which  the 
fingers  perform  other  motions  and  are  capable  of  being  used  for  every 
purpose  except  the  one  which  has  brought  on  the  disorder.  Pain, 
limited  to  the  affected  part,  or  more  extensive,  often  attends  this 
affection,  at  times  induced  only  by  writing,  at  other  times  spontane- 
ous. There  may  also  be  weakness  with  or  without  spasm,  and 
tremor,  and  local  vasomotor  manifestations,  such  as  glossiness  or 
turgid  discoloration  of  the  skin  and  undue  heat  and  sweating.  An 
analogous  complaint,  an ."  occupation  neurosis,"  too,  is  encountered 
in  seamstresses  ;  also  in  telegraph-operators,  particularly  those  who 
use  the  Morse  instrument.  These  cramps,  and  all  those  of  a  similar 
kind  caused  by  the  occupation,  such  as  in  piano-players,  in  violinists, 
and  in  type-writers,  car-drivers,  stone-masons,  cigarette-makers,  shoe- 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  193 

fitters/  have  the  same  diagnostic  sign  that  has  just  been  mentioned 
as  charcteristic  of  writers'  cramp,— namely,  that  the  spasm  befalls 
only  those  muscles  the  overstrain  of  which  has  led  to  the  affection, 
and  that  it  ceases  when  the  fatigued  muscles  are  kept  at  rest  or  are 
brought  into  action  for  a  different  purpose.  A  form  of  cramp  like 
that  of  writers'  cramp  happens  in  those  engaged  in  preparing  photo- 
graphic plates ;  2  and  I  have  seen  it  in  turners,  engaged  in  what  is 
called  "  oval  turning." 

There  is  a  disorder,  closely  aUied  to  chorea,  which  consists  in 
repeated  violent  bobbings  of  the  head,  lasting  many  minutes  at  a  time. 
These  salaam  convulsions,  as  Sir  Charles  Clarke  called  them,  are  a  very 
obstinate  complaint.  They  are  most  commonly  met  with  in  children, 
but  have  been  knoAvn  to  occur  in  adults^  and  to  lead  frequently  to 
impairment  of  the  intellect.* 

From  tetany  chorea  differs  in  the  spasm  of  the  former  being  inter- 
mittent, remittent,  or  continuous  and  tonic,  and  not  constant  and 
clonic.  The  nodding  movements  of  the  head,  sometimes  lateral, 
sometimes  rotary,  with  nystagmus,  observed  in  rhachitie  and  ill- 
nourished  infants  are  unlike  those  of  chorea. 

Hysteria.— Hysteria  manifests  itself  for  the  most  part  in  two 
forms,  in  convulsive  paroxysms,  or  in  local  hysterical  disorders.  The 
description  of  hysteria  here  will  deal  chiefly  with  the  symptoms  of  an 
hysterical  paroxysm.  Most  of  the  local  hysterical  affections  have  been, 
or  will  be,  considered  in  connection  with  the  diseases  they  ape ;  and 
to  attempt  to  scrutinize  or  to  interpret  connectedly  all  the  false  and 
contradictory  signals  this  perplexing  malady  hangs  out,  is,  in  a  work  of 
this  kind,  manifestly  impossible. 

An  hysterical  fit  may  set  in  suddenly,  under  the  influence  of  some 
violent  mental  emotion ;  but  more  generally  it  is  preceded  by  altered 
sphits,  by  a  sensation  of  pressure  and  of  constriction  at  the  pit  of  the 
stomach,  which  feeling  ascends  to  the  throat,  and  is  likened  by  the 
patient  to  the  rising  of  a  ball.  She  becomes  much  agitated,  sobs, 
laughs,  her  muscles  contract  violently,  or  she  hes  motionless,  and  ap- 
parently without  the  power  of  motion,  until  her  seeming  insensibility 
is  disturbed  by  something  she  disapproves  of,  or  fears.  The  heart 
palpitates  ;  the  breathing  is  often  accelerated,  u-regular,  and  heaving ; 
the  pupils  are  dilated,  their  reflex  gone.^ 

1  Moyer,  Medical  News,  Feb.  1893. 

^  Napias,  Gazette  Medicale  de  Paris,  No.  40,  1883. 

3  Levick,  Amer.  Journ.  Med.  Sci.,  Jan.  1862. 

*  Henry  Barnes,  Liverpool  and  Manchester  Hospital  Reports,  1873. 

5  Karplus,  Wiener  Med.  Wochens.,  No.  52,  1896. 


194 


MEDICAL   DIAGNOSIS. 


These  hytserical  outbursts  differ  from  the  spasms  of  chorea  by 
the  remissions,  the  patient  remaining  at  times  for  months  free  from 
the  convulsive  movements.  Moreover,  there  is  not  even  partial  or 
apparent  unconsciousness  in  chorea.  It  is  true  that  this  malady  and 
hysteria  are  sometimes  combined,  or  rather  that  chorea  happens  in 
hysterical  subjects,  and  is  then  brought  about  by  imitation,  and  is  apt 
to  come  on  suddenly ;  yet  it  is  remarkable  how  rarely  fits  of  hysteria 
take  place  in  those  affected  with  chorea. 

It  is  sometimes  very  difficult  to  distinguish  between  paroxysms  of 
hysteria  and  of  epilepsy  ;  and  it  becomes  the  more  difficult  if  the  epi- 
leptic seizures  occur  in  hysterical  patients.  Yet  there  are  ordinarily 
many  well-marked  points  of  distinction  between  the  two  maladies,  as 
will  be  seen  from  this  table  : 


Epilepsy. 

Usually  occurs  without   exciting    cause. 

Sets  in  with  a  scream. 

Sudden  and  complete  loss  of  conscious- 
ness. 

Livid  face ;  escape  of  frothy  saliva 
from  the  mouth ;  eyelids  half  open  ; 
eyeballs  rolling ;  grinding  of  the 
teeth ;  biting  of  the  tongue ;  more 
or  less  insensibility  of  the  pupils  to 
light. 

Distortion  of  countenance. 

Patient  evinces  no  feeling. 

Aura  epileptica. 

Convulsions  often  more  marked  on  one 
side  than  on  the  other  ;  and  at  first 
tonic  rather  than  clonic. 

Movements  unlike  voluntary  acts. 

May  pass  urine  involuntarily. 

Paroxysm  generally  of  short  duration. 

Paroxysm  followed  by  a  heavy,  half- 
comatose  sleep,  by  headache,  and  by 
dulness  of  intellect. 

Frequently  occurs  at  night. 

No  particular  connection  Avith  uterine 
or  ovarian  disturbance,  although  a 
paroxysm  often  takes  place  at  the 
menstrual  period. 


Hysteria. 

Often  induced  by  emotion. 

Noisy  during  attack. 

Gradual  and  only  partial  or  apparent 
unconsciousness. 

Face  flushed,  or  complexion  unaltered  ; 
no  froth  on  lips  ;  eyelids  closed  ;  eye- 
balls fixed ;  neither  grinding  of  the 
teeth  nor  biting  of  the  tongue  ;  pupils 
react  readily. 

A'o  distortion  of  countenance. 
Patient  sighs,  or  laughs,  or  sobs. 
Globus  hystericus. 

No  such  difference  ;  convulsions  tonic, 
followed  by  clonic. 

Movements  resemble  voluntary  acts. 

Copious  diuresis  afterwards. 

Paroxysm  generally  of  longer  duration. 

Paroxysm  not  followed  specially  by 
sleep ;  patient  often,  after  attack 
terminates,  wakeful  and  depressed  in 
spirits. 

Rarely  occurs  at  night. 

Often  connected  with  disorders  of  the 
uterus  or  ovaries,  or  of  menstrua- 
tion. 


There   are,    however,    spasms   that   occur   in   hysterical   patients 
which,  though  a  functional  nervous  affection,  appear  like  a  blending 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  195 

of  hysteria  and  epilepsy.  Charcot^  particularly  has  called  attention 
to  this  hystero-epilepsy,  and  descrii)es  its  distinctive  traits  as  consisting 
in  premonitory  symptoms  of  rather  long  duration,  and  exhibiting  an 
aura  yv^hich,  starting  in  most  cases  from  the  ovarian  region,  advances 
progressively  to  the  head.  The  cry  is  prolonged  and  modulated, 
not  short  like  the  epileptic  cry.  The  convulsions  are  identical ;  but, 
instead  of  entering  subsequently  upon  a  stage  of  snoring,  the  hystero- 
epileptic  sobs,  laughs,  gesticulates  violently,  or  is  delirious  and  subject 
to  hallucinations.  In  the  ovarian  form  of  hystero-epilepsy,  pressure 
upon  the  ovary  will  invariably  modify  the  symptoms,  if  not  com- 
pletely arrest  the  attack ;  whereas  in  epilepsy  no  such  effect  is  pro- 
duced. In  the  cases  of  hystero-epilepsy  with  repeated  attacks,  the  tem- 
perature scarcely  rises  above  the  normal,  as  jt  rapidly  does  under  similar 
circumstances  in  epilepsy.  There  is  no  epileptic  vertigo  ;  there  are  no 
abortive  fits.  The  malady  is  not  rarely  observed  in  men  and  in  children. 
Hysteria  is  a  psychoneurosis,  and  not  an  affection  merely  of  parox- 
ysms. In  the  intervals  between  them — there  may  be  no  paroxysms 
at  all — we  fmd  peculiar  and  significant  manifestations  which  should 
be  understood,  lest  they  be  taken  as  the  signs  of  other  maladies.  We 
observe  an  extreme  susceptibility  of  the  nervous  system,  with  defec- 
tive will-power  and  imperfect  self-control ;  irregular  or  depraved  ap- 
petite ;  flatulent  dyspepsia ;  constipation ;  interrupted,  sighing  respi- 
ration ;  rapid  action  of  the  heart ;  varied  hyperaesthesias,  such  as 
tenderness  in  the  epigastrium  or  in  the  course  of  the  spinal  column 
or  over  the  ovary  ;  that  peculiar  pain  in  the  left  side  which  distresses 
so  many  hysterical  and  ansemic  women ;  and  anaesthesia  often  con- 
fined to  a  circumscribed  area,  to  a  single  member  or  to  one  side  of 
the  body,  and  often  profound.  Besides  these,  we  encounter  mani- 
fold local  hysterical  ailments,  such  as  hysterical  paralysis,  hysterical 
aphonia,  hysterical  tremor,  hysterical  anorexia,  hysterical  peritonitis, 
hysterical  affections  of  joints,  hysterical  pain  in  the  forehead,  hys- 
terical haemoptysis,  hysterical  barking  cough,  hysterical  sweating, 
hysterical  suppression  as  well  as  hysterical  retention  of  urine.  Hys- 
terical laughter  has  been  found  to  occur  on  a  large  scale  as  a  form 
of  epidemic  convulsion.^  There  may  be  hysterical  deafness,  or  hys- 
terical amaurosis,  or  retinal  hyperaesthesia,  or  crossed  amblyopia. 
J.  K.  Mitchell  and  de  Schweinitz  ^  consider  disturbance  of  color-sense 


^  Lectures  on  Diseases  of  the  Nervous  System.       See  also  Richer,  Etudes  cH- 
riiques  sur  Hystero-l^pilepsie,  Paris,  1881. 
■'  D.  W.  Yandell,  Brain,  Oct.  1881. 
**  Journal  of  Mental  and  Nervous  Diseases,  vol.  xix.,  No.  1,  p.  1. 


196  MEDICAL  DIAGNOSIS. 

common  in  hysteria.  They  have  found  reversal  in  the  normal  se- 
quence of  colors  to  be  usually  preset  in  cases  attended  with  anees- 
thesia.  Muscular  atrophy  has  been  observed  as  a  manifestation  of  hys- 
teria ;  ^  a  low-grade  optic  neuritis  has  led  to  the  supposition  of  cerebral 
tumor  ;^  and  a  case  has  been  recorded  closely  simulating  syringo- 
myelia.^    In  hysterical  insanity  a  suicidal  tendency  is  often  noticed. 

Hysteria  is  met  with  in  the  male,  especially  after  railway  acci- 
dents. Hysterical  paralysis  may  also  happen  in  either  sex,  in  the 
shape  of  hemiplegia,  of  monoplegia,  or  of  paraplegia,  and  may  be 
of  extremely  long  duration.*  As  regards  hysterical  hemiplegia,  it  is 
remarkable  that  it  does  not  affect  the  face  ;  yet  there  may  be  an  hys- 
terical facial  paralysis.^  Hysterical  headache,  Charcot  tells  us,  like 
syphilitic,  increases  at  night,  and  is  similar  to  the  tremor  from  metallic 
poisons.  Hysterical  tremor  is  most  common  in  the  hands  and  arms. 
Hysterical  contractures  may  occur  in  both  arm  and  leg;  complete 
anaesthesia  causes  them  to  disappear  temporarily.  The  reflexes  in 
hysteria  may  be  much  deranged.  As  Goodell  ^  well  says,  strange  and 
misleading  reflexes  come  from  the  loss  of  brain  control  over  the  in- 
subordinate lower  nerve-centres.  In  toxic  hysteria^  such  as  we  observe 
after  chronic  lead  or  mercurial  poisoning,  tremor,  anaesthesia,  palsies, 
and  anorexia  or  hysterical  vomiting  are  often  observed, — much  oftener 
than  hysterical  paroxysms. 

Fever  is  not  a  symptom  of  hysteria.  Yet  occasionally  we  meet 
with  cases  that  it  is  difficult  to  explain  in  any  other  way,  and  hys- 
terical disturbance  of  the  heat-centres  with  extraordinarily  high  tem- 
peratures certainly  happen.  We  may  also  have  fever  in  hysterical 
local  diseases,  as  in  hysterical  meningitis,  in  hysterical  peritonitis. 

The  distinction  between  these  hysterical  pseudo-maladies  and  the 
diseases  they  simulate  is  far  from  being  an  easy  task.  We  have  to 
take  into  account  the  patient's  age  and  sex  ;  whether  or  not  she  has 
suffered  from  paroxysms  of  hysteria ;  how  the  pain  is  influenced  by 
pressure  ;  the  great  tendency  to  exaggeration  and  deception ;  and  the 
signs  of  functional  disorder  of  the  apparently  affected  part.  We  may 
thus  avoid  mistaking  a  phantom  for  a  true  disease.  Yet  there  is 
another  and   opposite   source  of  error  quite   as   strenuously  to  be 

^  Hirst,  Deutsche  medicinische  Wochenschrift,  1894,  No.  21,  p.  459. 
^  Mills,  The  Nervous  System  and  its  Diseases,  1898,  p.  527. 

*  Wichmann,  Berliner  klinische  Wochenschrift,  1895,  No.  12,  p.  252. 

*  See  cases  reported  by  Morton  Prince,  of  twenty-nine,  twenty-eight,  and 
twenty-nine  years'  duration,  Amer.  Journ,  Med.  Sci.,  July,  1892. 

^  Babinski,  Societe  Medicate  des  Hopitaux  de  Paris,  1892. 
«  Medical  News,  Jan  6,  1894. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  197 

guarded  against.  The  complaint  may  be  really  an  organic  one,  oc- 
curring in  an  hysterical  patient,  and  concealed,  or  exaggerated  and 
complicated,  by  the  symptoms  of  hysteria.  In  all  such  doubtful  cases 
we  must  accord  great  weight  to  the  extent  of  functional  and  constitu- 
tional disturbance  accompanying  the  local  morbid  state.  Then,  too, 
hysterical  symptoms  may  be  prominent  in  certain  brain  and  cord 
affections,  I  have  repeatedly  noticed  them  in  cases  of  cerebral  em- 
bolism ;  and  Brown-Sequard  and  Seguin  ^  have  shown  their  frequent 
occurrence  in  lesions  of  the  right  hemisphere.  In  hysterical  attacks 
connected  with  a  cerebral  neoplasm,  the  urea  and  the  phosphates  in 
the  urine,  Gilles  de  la  Tourette^  shows,  are  diminished,  while  in 
epileptic  seizures  connected  with  brain  tumors  they  are  increased. 
Hysteria  may  also  complicate  myelitis  and  lateral  sclerosis. 

Hysteria  is  sometimes  feigned, — feigned  to  elicit  sympathy,  or  to 
procure  compliance  with  wishes  or  caprices.  Nor  is  the  simulation 
of  the  disorder  an  outgrowth  of  our  civilization.  The  epigrams  of 
Martial  prove  how  common  the  feigning  of  hysteria  was  among  the 
Roman  women. 

Tetanus. — A  very  fatal  disease  marked  by  persistent  rigid  con- 
traction of  the  voluntary  muscles,  particularly  of  those  of  the  jaw, 
with  violent  brief  exacerbations. 

This  distressing  malady,  as  we  see  it,  is  generally  traumatic^  follow- 
ing a  wound,  or  an  injury ;  for  idiopathic  tetanus  is  very  seldom  met 
with  in  temperate  climates.  But  in  hot  countries,  or  in  those  in 
which  sudden  alternations  of  temperature  are  common,  it  is  not  a 
rare  disease,  and  is  indeed  frequent  among  new-born  children.  The 
malady  is  also  seen  in  the  puerperal  state. 

The  symptoms  of  tetanus  depend  upon  the  action  of  a  poison  gen- 
erated by  a  special  micro-organism,  the  bacillus  tetani.  This  is  a  long, 
slender  bacillus,  found  commonly  in  the  superficial  layers  of  earth, 
and  growing  best  in  the  absence  of  air  and  light.  It  is  usually  met 
with  in  the  local  lesion.  In  the  so-called  idiopathic  cases  the  channel 
of  microbic  infection  eludes  detection. 

The  muscles  ordinarily  first  affected  are  those  of  the  jaw  and  neck  ; 
there  is  a  stiffness  about  them  which  the  patient  is  apt  to  attribute  to 
having  caught  cold.  Sometimes,  however,  the  disorder  exhibits  itself 
primarily  in  the  external  respiratory  muscles.  When  the  malady  is 
fully  developed,  most  of  the  muscles  are  stiff  and  hard,  the  jaw  can- 
not be  opened, — whence  the  common  name  of  lock-jaw, — and  there 

^  Archives  of  Electrology  and  Neurolo|jry,  May,  1875. 
''  Quoted,  Lancet,  May,  1893,  p.  1083. 


198  MEDICAL  DIAGNOSIS. 

is  much  difficulty  in  speaking  and  in  swallowing.  The  face  is  dis- 
torted, presenting  the  "  risus  sardonicus."  With  these  symptoms  we 
usually  find  rigidity  of  the  muscles  of  the  abdomen  and  of  the  limbs, 
and  a  distressing  pain  at  the  pit  of  the  stomach,  dependent  upon 
spasm  of  the  diaphragm.  Besides  the  permanent  contraction  of  the 
voluntary  fibres,  exacerbations  of  spasm  take  place,  during  which  the 
muscles  become  very  hard.  These  paroxysms  are  accompanied  by 
intense  pain,  and  recur  with  increased  severity  and  frequency  as  the 
disease  advances  to  a  fatal  termination.  When  at  their  height,  the 
body  becomes  curved,  the  patient  merely  resting  upon  his  head  and 
heels.  This  is  opisthotonos ;  while  the  setting  of  the  jaw,  especially 
when  its  muscles  alone  are  affected,  is  called  trismus.  The  trunk  may 
be  bent  forward, — emprosthotonos  ;  or  to  one  side, — pleurothotonos  j  or 
the  trunk  and  neck  are  rigidly  extended  in  a  straight  line, — orthotonos. 
The  spasm  relaxes  during  natural  sleep  or  induced  narcosis.  At  the 
height  of  the  attack  the  body  is  covered  with  copious  perspiration. 

Notwithstanding  the  striking  muscular  disorder  and  the  exhaust- 
ing pain,  there  is  little  constitutional  disturbance ;  the  pulse  may  be 
quickened,  but  it  preserves  its  volume  until  the  last  stage  is  reached ; 
and  there  is  no  fever,  certainly  not  in  the  earlier  stages,  nor  is  the 
intellect  affected.  Yet  the  temperature  shows  extraordinary  varia- 
tions. The  thermometer  may  mark  an  increase  of  several  degrees 
in  the  evening,^  and  towards  the  end  indicate  a  heat  of  110°  F.,  even 
continuing  to  rise  after  death. 

When  tetanus  results  from  an  injury  to  the  head,  and  more  par- 
ticularly in  the  distribution  of  the  fifth  nerve,  there  is  often,  in  addi- 
tion to  the  initial  trismus,  paralysis  of  the  face  on  the  same  side  as  the 
injury,  and  spasm  on  the  opposite  side. 

Tetanus  runs  an  acute  or  a  chronic  course.  Some  cases  last  three 
weeks,  and  when  of  such  long  duration  are  apt  to  recover.  But  gen- 
erally the  malady  terminates  fatally  before  the  eighth  day. 

Few  complaints  are  likely  to  be  confounded  with  tetanus  ;  yet 
these  few  resemble  it  in  many  respects  closely.  For  instance,  one  of 
the  freaks  of  hysteria  is  to  take  the  appearance  of  tetanus  ;  and  tonic 
spasms  dependent  upon  an  affection  of  the  spinal  cord  or  medulla 
oblongata,  strychnine  poisoning,  or  hydrophobia,  may  accurately  sim- 
ulate its  symptoms. 

Hysterical  tetanus  is  distinguished  from  the  real  disease  by  being 
preceded  by,  or  attended  with,  fits  of  hysteria ;  by  the  age  and  sex  of 
the  patient ;  by  the  absence  of  pain ;  by  the  occasional  occurrence  of 

^  Ogle,  Clinical  Society's  Transactions,  1872. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  199 

clonic  instead  of  tonic  spams  ;  and  by  the  intermission  every  now  and 
then  of  all  muscular  rigidity.  Moreover,  the  influence  of  the  mind 
upon  the  seeming  tetanus  is  very  striking.  If  within  hearing  of  the 
patient  the  employment  of  cold  to  the  spine,  or  of  the  cautery,  be 
threatened,  or,  better  still,  if  the  latter  instrument  be  actually  made 
ready  for  use  before  her,  an  extraordinary  subsidence  of  all  stiffening 
and  starting  of  the  limbs  takes  place.  Hysterical  trismus  is  more 
common  than  extended  hysterical  tetanoid  spasm,  but,  besides  the 
symptoms  of  hysteria  just  mentioned,  the  absence  of  rigidity  in  the 
neck  is  very  significant. 

Tetanic  spasms  symptomatic  of  an  affection  of  the  spinal  cord  are 
separated  from  tetanus  by  the  different  history ;  by  no  violent  exacer- 
bations being  brought  on,  as  they  are  in  tetanus,  by  slight  movements, 
or  by  an  attempt  at  speaking,  or  by  any  reflex  irritation ;  by  the  ab- 
sence of  marked  remissions  ;  by  the  rigidity  being  almost  always  lim- 
ited to  the  extremities, — except  in  the  case  of  meningeal  apoplexy  in  the 
cervical  region,  in  which  the  tonic  contraction  in  the  upper  extremity 
is  associated  with  stiffness  of  the  neck  ;  by  its  association  with  altered 
sensibility  ;  and  by  the  setting  in  of  palsy  before  the  malady  terminates. 

In  the  tetanic  spasms  which  may  occur  in  scarlet  fever,  in  typhus, 
in  smallpox,  or  in  pyaemia,  and  which  are  the  result  of  an  irritation 
of  the  cord  produced  by  the  poisoned  blood,  the  rigidity  runs  so  un- 
certain a  course,  appears  so  quickly,  disappears  so  suddenly,  perhaps 
not  to  return,  or  only  to  reappear  after  a  considerable  interval,  that 
there  is  little  likelihood  of  confounding  the  muscular  disorder  with 
tetanus.  Tetanus  differs  from  meningitis  in  the  absence  of  pyrexia,  of 
headache,  and  of  vomiting ;  in  the  early  presence  of  trismus,  which, 
indeed,  in  meningitis  may  be  wholly  wanting ;  and  in  the  fact  that  the 
spasms  in  this  are  generally  only  induced  on  attempted  movement, 
whereas  in  tetanus  the  reflex  irritability  is  so  great  that  they  are  in- 
duced by  the  slightest  touch.  In  cerebro-sjnnal  fever  the  resemblance 
is  much  closer ;  yet  the  whole  history  of  the  disorder,  the  marked 
headache  and  mental  symptoms,  the  fever,  and  the  progress  of  the 
case,  are  such  as  to  prevent  error.  With  muscular  rheumatism  tetanus 
can  only  be  confounded  at  its  onset ;  but  the  muscles  of  the  jaw  are 
not  rigid  in  rheumatism. 

Another  form  of  symptomatic  rigidity  requires  it  to  be  distinguished 
from  tetanus, — a  local  rigidity,  owing  to  irritation  of  the  nerve  supply- 
ing the  stiffened  muscles ;  as,  for  instance,  a  spasm  from  irritation  of 
the  peripheral  or  the  central  tract  of  the  motor  portion  of  the  fifth, 
the  so-called  masticatory  spasm  of  the  face.  The  ailment  may  be  of 
reflex  origin,  the  exciting  cause  being  a  decayed  tooth,  a  wound,  or 


200  MEDICAL  DIAGNOSIS. 

exposure  to  cold  ;  or  it  may  exist  in  connection  with  apoplexy,  or  with 
an  inflammation  of  the  brain.  Its  main  marks  of  distinction  from  the 
trismus  of  tetanus  are,  that  it  is  purely  local,  is  often  of  long  contin- 
uance, is  not  painful,  has  no  paroxysms  of  aggravation,  is  not  com- 
bined with  impaired  deglutition,  and  is  not  dangerous.^  Similar 
spasm  has  also  been  observed  as  a  result  of  irritative  lesions  of  the 
pons,  such  as  a  new  growth,  or  vascular  disease,  affecting  the  motor 
nucleus  of  the  fifth  nerve. 

Tetany  is  characterized  by  tonic  contractions,  more  especially  of 
the  legs  and  arms,  which  may  be  intermittent,  remittent,  or  con- 
tinuous ;  the  toes  are  apt  to  be  flexed  towards  the  soles ;  the  hands 
become  fixed ;  the  spasm,  dissimilar  to  what  happens  in  tetanus,  begins 
in  the  extremities.  The  jaws  and  the  respiratory  muscles  are,  unlike 
what  we  find  in  tetanus,  not  affected,  or  the  jaws  become  so  only 
towards  the  end  in  severe  cases. 

The  spasms  are  painful ;  they  may  occur  several  times  in  a  day,  or 
there  may  be  weeks  between  them.  They  also  can  be  produced,  as 
Trousseau  discovered,  by  pressure  on  the  chief  arteries  and  nerves 
of  the  affected  limb.  They  are  usually  preceded  by  tingling  or  burn- 
ing ;  in  the  intervals  between  them  the  muscles  are  readily  excited  to 
contraction  and  there  is  increased  electrical  excitability ;  the  tempera- 
ture, as  a  rule,  remains  normal  throughout,  although  in  severe  parox- 
ysms it  may  be  elevated,  and  there  may  be  copious  perspiration.  The 
irritability  of  both  sensory  and  motor  nerves  is  increased ;  and  the 
remarkable  irritability  is  shown  by  ChorsteFs  symptom, — a  slight  tap 
in  the  course  of  the  nerve,  as  of  the  facial,  will  throw  the  muscles  to 
which  it  goes  into  strong  contractions.  The  contractions  in  tetany 
are  bilateral,  which  distinguishes  them  from  hysterical  contractures. 
Tetany  differs  from  carpopedal  spasm,  observed  in  rickets  or  in  severe 
gastro-intestinal  catarrh,  by  the  spasms  of  this  being  much  more  tran- 
sient. They  are  also  apt  to  be  much  more  marked  in  the  fingers  than 
in  the  toes.  But  the  distinction  is  chiefly  one  of  degree,  and  many  re- 
gard carpopedal  spasm  as  only  a  light  form  of  tetany.  This  malady 
happens  chiefly  in  rhachitic  children,  as  a  sequel  of  exhausting  diar- 
rhoea, after  exposure  to  cold,  and  in  nursing  or  in  pregnant  women ; 
it  has  also  been  observed  in  connection  with  dilatation  of  the  stom- 
ach and  after  removal  of  the  thyroid  gland.  It  has  been  described 
as  occurring  in  an  epidemic  form,  and  the  symptoms  are  like  those  of 


1  Bright,  in  the  second  volume  of  his  Medical  Reports,  gives  the  particulars  of 
a  case  v^rhich  illustrates  many  of  the  difficulties  of  diagnosis  to  which  the  affection 
may  give  rise. 


DISEASES  OF  THE  BEAIN   AND  SPINAL   CORD.  201 

ergot  poisoning.^     The  disease  is  not  a  common  one  in  this  country. 
Crozer  Griffith  ^  has  analyzed  seventy-two  cases  reported  in  America. 

The  symptoms  of  strychnine  poisoning  are  ahuost  identical  with 
those  of  tetanus  ;  yet  there  are  some  characteristic  differences.  The 
spasms  from  strychnine  do  not  supervene  upon  exposure  to  cold,  or 
upon  a  wound,  but  follow  within  about  two  hours  or  less  the  taking 
of  some  solid  or  liquid.  They  come  on  suddenly,  with  violence,  with 
epigastric  pain  and  early  reflex  excitability.  The  tetanoid  convul- 
sions affect  simultaneously  nearly  all  the  voluntary  muscles  of  the 
body,  but  with  greatest  intensity  those  of  the  trunk  and  spine,  pro- 
ducing very  early — within  a  few  minutes,  commonly — a  marked  opis- 
thotonos, which  in  tetanus  does  not  appear,  if  it  appear  at  all,  for 
many  hours  or  days  after  the  seizure.  On  the  other  hand,  the  stiff- 
ness of  the  jaws,  which  is  among  the  very  earliest  signs  of  tetanus,  is 
not  at  first  perceived  in  strychnine  poisoning,  and,  if  it  occur,  occurs 
only  imperfectly.  Further  we  do  not  see  the  frightful  tetanic  face, 
with  its  knit  brow  and  horrid  grin ;  we  do  not  observe  intermissions 
in  the  convulsions,  or  difficulty  in  swallowing ;  and  in  from  ten  min- 
utes to  two  hours  after  the  commencement  of  the  attack  the  patient 
dies  or  recovers. 

Finally,  let  us  contrast  tetanus  with  hydrophobia.  Both  showing 
the  reflex  functions  of  the  spinal  cord  to  be  in  an  exalted  condition ; 
both  being  spasmodic  affections  lasting  ordinarily  but  a  few  days ; 
both  taking  place,  the  popular  opinion  to  the  contrary  notwithstand- 
ing, at  all  periods  of  the  year ;  both  presenting  violent  paroxysms  of 
convulsions,  which  are  often  excited  by  the  slightest  touch  or  jar  to 
the  body ;  both  frequently  occasioning  torturing  pain  near  the  pit  of 
the  stomach ;  both  ensuing  commonly  upon  an  injury  ;  both  usually 
augmenting  in  intensity  from  hour  to  hour, — these  ghastly  maladies 
are  yet  dissimilar.  The  one  results  from  infection  with  a  specific 
bacillus  often  present  in  earth ;  the  other  from  infection  with  the 
virus  of  a  rabid  animal,  most  commonly  the  dog  or  the  wolf.  The 
one  has  a  short,  the  other  a  long  period  of  incubation.  In  the  one, 
deglutition  may  be  difficult ;  in  the  other,  it  is  next  to  impossible,  all 
attempts  at  swallowing,  especially  of  fluids,  exciting  the  most  dis- 
tressing spasmodic  dysphagia.  In  the  one,  early  rigidity  of  the  mus- 
cles of  the  jaw  happens ;  in  the  other,  there  is  no  such  rigidity.  In 
the  one,  the  breathing  may  or  may  not  be  interfered  with ;  in  the 
other,  the  spasms  of  respiration  are  almost  as  marked  a  feature  as 

^  Stated  ill  the  German  translation  of  this  book. 
^  Trans,  of  the  Assoc,  of  Arnev.  Phys.,  vol.  ix.,  1894. 
18 


202  MEDICAL  DIAGNOSIS. 

the  spasms  of  deglutition.  Then  the  irritabihty  of  temper  in  hydro- 
phobia ;  the  fierce  manner  of  the  patient ;  his  rabid,  perhaps  maniacal 
paroxysms  ;  the  constant  thirst ;  the  accumulation  of  stringy  mucus 
about  the  angles  of  the  mouth  ;  the  vomiting  ;  the  acute  sensibility  of 
the  surface ;  the  trembling  of  the  muscles  ;  the  clonic  instead  of  tonic 
spasms  ;  the  husky  voice  ;  the  strangling  sensation  in  the  throat,-^are 
phenomena  too  striking  to  render  an  error  in  diagnosis  likely.  The 
temperature  is,  as  a  rule,  elevated,  and  in  direct  proportion  to  the 
intensity  of  the  other  symptoms.  Towards  the  close  it  may  reach  a 
high  degree,  and  it  sometimes  continues  to  rise  after  death.  Some 
of  the  points  here  referred  to  serve  also  to  distinguish  hydrophobia 
from  acute  mania,  and  from  hysteria.  For,  as  in  tetanus,  we  find  this 
erratic  complaint  simulating  the  terrible  disease.  In  truth,  it  is  the 
opinion  of  some,  of  Dulles^  especially,  that  the  great  majority  of 
cases  of  supposed  hydrophobia  are  of  this  character. 

Functional  Spasms. — There  are  spasms  that  take  place  in  vari- 
ous parts  of  the  body,  sometimes  clonic  spasms,  sometimes  tonic 
spasms,  which  occur  without  apparent  cause,  and  are  more  or  less 
continuous  or  persistent.  In  time  they  may  lead  to  contractures  and 
deformity,  or  they  may  pass  away.  They  may  be  of  hysterical  origin  ; 
but  these  are  not  now  under  discussion,  rather  the  spasms  that  take 
place  in  one  or  both  legs,  sometimes  in  the  arms,  occasionally  in  the 
muscles  of  the  face,  which  occur  in  those  who  are  not  hysterical  sub- 
jects, and  are  not  traceable  to  any  lesions.  Pressing  on  particular 
points  may  at  once  excite  them  ;  on  the  other  hand,  there  are  "  press- 
ure-points" which  when  acted  on  will  cause  the  convulsive  move- 
ments to  be  arrested.  The  trophic  disturbance  that  attends  them  is 
usually  very  slight.  Tonic  contractions  are  apt  to  alternate  with 
clonic  spasms,  or  there  may  be  only  complete  tonic  spasm  during 
attempts  at  moving  certain  muscles.  At  times  spasms  of  the  internal 
muscles,  as  those  of  deglutition  or  respiration,, may  coexist;  or  the 
spasms  may  be  limited  to  these  muscles.  The  disorder  is  sometimes 
hereditary. 

There  is  a  curious  form  of  spasm,  a  tonic  contraction  of  the  mus- 
cles, which  impedes  locomotion.  It  shows  itself  when  the  muscles 
are  first  put  into  action  after  a  period  of  rest,  or  after  an  unexpected 
irritation,  as  striking  the  toes  against  a  stone  in  walking,  and  is  aug- 
mented by  nervous  dread  about  it.  Happening,  as  it  generally  does, 
in  the  lower  extremities,  it  leads  there  to  muscular  increase.     This 

^  Transactions  of  the  College  of  Physicians  of  Philadelphia.  3d  Ser.,  vol.  xvi., 
1894. 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  203 

Thomseii's  disease,  or  congenital  or  transient  myotone,  has  been  known 
to  originate  in  sudden  fright.^  It  begins  commonly  at  an  early  age, 
and  is  hereditary  ;  it  is  persistent,  although  no  organic  cause  for  it  has 
been  detected.  In  one  fatal  case  post-mortem  examination  disclosed 
the  existence  of  hyperplasia  of  the  muscular  tissue,  without  appre- 
ciable lesion  of  the  central  or  peripheral  nervous  apparatus.^  The 
difficulty  is  most  marked  in  the  morning,  on  first  rising,  attempts  at 
movement  causing  the  muscles  to  become  rigid  and  the  joints  fixed : 
yet  if  exertion  be  persevered  in,  the  spasm  becomes  less  and  less,  and 
continued  walking  is  possible  until  after  another  period  of  rest.  The 
spasm  is  ag-gravated  by  attention  and  emotion,  and  very  rarely  affects 
the  muscles  of  the  face.  Electrical  and  mechanical  irritability  are 
heightened.     Sensibility  and  reflex  excitability  are  unaffected. 

The  chief  difference  between  Thomsen's  disease  and  'paramyotone^^ 
which  is  also  a  family  affection,  is,  that  in  the  latter  spasm  is  not 
started  by  voluntary  movements  and  is  more  permanent ;  the  marked 
spasms  may  last  several  hours.  They  are  excited  by  cold  and  allayed 
by  warmth.     Paramyotone  may  be  associated  with  ataxic  symptoms. 

A  family  type  of  congenital  myotone  is  described  by  Eulenburg,* 
and  intermittent  congenital  myotone  by  Martin  and  Hausemann,^  in 
both  of  which  exposure  to  cold  was  followed  by  tonic  spasm  of 
various  muscles.  The  irritability  of  the  affected  muscles  was  dimin- 
ished. It  is  not  impossible  that  future  investigation  may  disclose 
some  relationship  between  the  spasmodic  conditions  here  described 
and  some  of  the  forms  of  functional  palsy  previously  detailed. 

Hiccough. — As  a  form  of  local  spasm  may  be  here  mentioned 
the  curious  phenomenon  called  hiccough,  an  intermittent,  sudden 
contraction  of  the  diaphragm.  It  is  a  matter  of  doubt  whether  this 
is,  connected  with  irritation  of  the  respiratory  centre,  or  is  a  spasm 
from  irritation  of  the  phrenic  nerve,  reflected,  it  may  be,  from  the 
pneumogastric,  or  direct.  Its  symptoms  are  a  spasmodic  contraction 
of  the  diaphragm,  followed  by  a  sudden  closure  of  the  glottis  with  a 
short,  cough-like  noise.  It  may  occur  in  brief  paroxysms  of  varying 
duration,  or  go  on  by  day  and  night,  and  result  in  wearing  out  the 

1  Case  of  Schonfeld,  Berliner  klinische  Wochenschrift,  July,  1883. 

^  Dejerine  and  Sottas,  Compt.-rend.  hebdom.  des  seances  de  la  Soc.  de  Biol., 
1893,  No.  23,  p.  669. 

^  Gowers,  Diseases  of  the  Nerves  and  Spinal  Cord,  vol.  i.,  1899. 

*  Neurologisches  Centralblatt,  1886,  No.  12  ;  Jahresber.  liber  die  Leist.  u. 
Fortschr.  i.  d.  ges.  Med.,  xxi.  2,  p.  164. 

^  Arch.  f.  path.'Anat.  u.  Physiol,  u.  f.  klin.  Med.,  cxvii.  7,  p.  587;  Jahres- 
ber. iiber  die  Leist.  u.  Fortschr.  i.  d.  ges.  Med.,  xxiv.  2,  p.  76. 


204  MEDICAL  DIAGNOSIS. 

strength  of  the  patient.  It  is  met  with  in  various  affections,  both  of 
the  nervous  system  and  of  the  oesophagus,  stomach,  and  intestines. 
In  some  instances  it  is  clearly  of  rheumatic,  or  gouty,  or  ursemic,  or 
other  toxsemic  origin.  When  traceable  to  the  nervous  system,  it  may 
be  centric,  due  to  the  pressure  of  localized  inflammatory  exudation, 
or  of  a  new  growth,  or  be  the  result  of  reflected  irritation.  When 
met  with  in  diseases  of  the  stomach,  the  irritation  is  peripheral  and 
clearly  reflected.  In  persons  with  atonic  and  flatulent  dyspepsia  or 
catarrhal  conditions  of  the  stomach,  hiccough  is  not  an  uncommon 
symptom.  Hiccough  is  also  seen  in  diaphragmatic  pleurisy,  in  dysen- 
tery, in  appendicitis,  in  peritonitis,  and  in  disease  of  the  heart.  Irre- 
spective of  the  causes  that  are  distinctly  centric,  or  are  peripheral  and 
reflected  through  the  pneumogastric  nerve,  cases  of  hiccough  occur 
that  cannot  be  traced  to  any  obvious  cause,  and  in  which  it  appears 
as  a  pure  neurosis.  These  are  apt  to  be  among  the  most  obstinate 
ones  ;  many  of  them  occur  in  hysterical  subjects. 

Diseases  of  Ill-Regulated  or  Deficient  Nerve-Force. 

The  diseases  which  principally  belong  here  are  hysteria  and  neu- 
rasthenia ;  in  both  there  is  also  marked  psychic  perversion.  Hysteria 
has  already  been  descril^ed  in  its  most  striking  form, — the  convulsive. 
This  brings  it  into  the  group  marked  by  convulsions  or  spasms,  with 
which  it  is  most  conveniently  considered. 

Neurasthenia. — The  weakness  of  the  nervous  system  shows 
itself  as  a  general  state  of  nervous  exhaustion,  or  as  the  nervous 
weakness  of  special  parts,  such  as  cerebral  neurasthenia,  spinal 
neurasthenia,  sexual  neurasthenia,  gastro-intestinal  neurasthenia, 
cardiac  neurasthenia,  and  vasomotor  neurasthenia.  There  are  no 
strict  differences  between  these  forms,  and,  even  in  these  local  mani- 
festations, the  evidences  of  a  general  neurasthenic  state  may  be 
found.  Neurasthenia  may  be  from  inborn  nervous  weakness ;  or 
acquired  from  strain  of  life,  anxiety,  worry,  loss  of  sleep,  eye-strain, 
from  effort  made  too  soon  after  exhausting  disease,  from  prolonged 
mental  labors  undertaken  by  those  who  lead  in-door  lives  ;  or  trau- 
matic, as  seen  especially  after  railway  accidents. 

The  symptoms  of  the  general  neurasthenic  state  are  manifold. 
There  is  generally  weakness,  which  becomes  painfully  manifest  on  any 
sustained  bodily  or  mental  exertion,  some  loss  of  weight,  and  a  de- 
pressed or  despondent '  look.  Anaemia  and,  in  women,  hysterical 
manifestations  are  not  uncommon,  and  low  spirits  are  general,  though 
cheerfulness  is  also  met  with.  As  a  rule,  there  is  insomnia,  as  well 
as  a  sense  of  weight  and  pressure  in  the  head,  pain  at  the  back  of  the 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  205 

neck,  and  inability  to  fix  the  attention  on  any  subject  for  long,  cer- 
tainly to  do  so  without  fatigue.  All  business  affairs,  even  the  smallest, 
become  a  source  of  worry,  of  annoyance,  of  self-reproach.  The 
temper  is  irritable,  and  the  patient  is  constantly  talking  of  himself, 
his  symptoms,  his  sufferings.  The  appetite  may  remam  good,  but  it 
is  often  impaired,  and  there  is  a  condition  of  nervous  dyspepsia  with 
litheemic  urine.  The  eye  is  sensitive,  and  aching  in  the  eyeball  after 
reading  or  flashes  of  light  are  complamed  of;  there  is,  indeed,  a  very 
familiar  neurasthenic  asthenopia.  Inequality  of  the  pupils  and  their 
dilatation  and  drooping  of  one  eyelid  are  usual.  Both  the  deep  and 
superficial  reflexes  are  increased,  and  hyperaesthesia,  especially  in- 
creased sensitiveness  to  pain,  is  common.  Then  there  are  pain  or 
aching  in  the  back  and  spine,  and  various  neuralgic  pains  and  dizziness. 
In  some  instances  the  psychical  phenomena  preponderate.  There  is 
intense  dread  of  one  object  or  the  other,  of  people,  of  things,  of  dis- 
ease, of  insanity,  curious  and  uncontrollable  thoughts  run  through  the 
mind,  and  suicidal  tendencies  may  show  themselves.  The  will-power 
is  greatly  impaired  ;  there  is  an  inability  to  come  to  any  decision.  The 
vasomotor  disturbances  show  themselves  by  flushes  of  heat,  sweat- 
ing, and  throbbing  of  the  abdominal  aorta,  as  wefl  as  general  arterial 
throbbing  and  imperfect  capillary  circulation,  with  coldness  of  hands 
and  feet  and  numbness. 

Accordingly  as  one  or  the  other  group  of  symptoms  preponderates, 
we  have  different  local  types  established,  and  among  these  the  cere- 
bral and  the  spinal  may  be  very  confusing,  and  readily  lead  to  the 
supposition  of  organic  disease. 

The  cerebral  I  described  years  ago  m  the  first  edition  of  this  work 
(1864)  as  '-'  exhaustion  of  brain  power,"  and  pointed  out  how  it  differs 
from  the  phenomena  generally  attributed  to  softening  of  the  brain.  It 
is  encountered  among  overworked  professional  men  or  those  engaged 
in  laborious  literary  undertakings.  It  sometimes  comes  on  suddenly, 
with  signs  like  those  of  collapse  ;  more  generafly  it  is  slower  in  de- 
velopment. Its  manifestations  are  a  slight  deterioration  of  memory, 
and  an  inability  to  read  or  write,  save  for  a  very  short  period,  although 
the  power  of  thought  and  of  judgment  is  in  no  way  perverted.  Nor 
is  the  power  of  attention  more  than  enfeebled :  the  sick  man  is  fully 
capable  of  giving  heed  to  any  subj'ect,  but  he  soon  tires  of  it,  and  is 
obliged  from  very  fatigue  to  desist.  He  passes  sleepless  nights,  is  sub- 
ject to  rmging  in  the  ears,  cannot  bear  much  exercise,  is  troubled  with 
irregular  action  of  the  heart,  with  a  frequent  desire  to  urinate,  and 
with  neuralgic  pains  in  the  face  or  a  feeling  of  soreness  in  the  head ; 
but  he  does  not  generally  lose  flesh,  and  his  digestion  is  unimpaired. 


206  MEDICAL   DIAGNOSIS. 

Many  remain  in  this  condition  for  months,  and  then  slowly  regain 
their  health.  What  the  precise  disturbance  of  the  brain  consists  in  is 
uncertain  :  it  is  possible  that  the  nutrition  of  the  organ  has  been  inter- 
fered with  from  overuse  and  worry.  The  phenomena  of  this  cerebral 
neurasthenia^  as  it  is  now  customary  to  call  the  disorder,  differ  from 
those  of  softening  by  the  absence  of,  or  at  least  by  the  far  less  per- 
manent and  marked,  headache,  by  the  comparatively  unimpaired  intel- 
ligence, and  by  the  non-occurrence  of  spasms  or  of  paralysis,  and  of 
the  causes  that  generally  produce  softening. 

Cerebral  neurasthenia  may  be  mistaken  for  the  earlier  stages  of 
general  paresis.  But  though  they  have  signs  of  nervous  weakness 
and  exhaustion  in  common,  and  even  some  of  the  psychic  manifesta- 
tions, yet  the  slowness  of  speech,  the  tremor  of  the  tongue,  the  condi- 
tion of  the  pupil,  generally  myotic  and  with  impaired  reflex,  and  the 
change  in  character  denote  the  paretic  affection,  in  which,  moreover, 
there  is  often  a  history  of  syphilis  or  of  alcoholism.  In  the  more  ad- 
vanced stages  of  the  malady  the  impaired  gait,  the  almost  unintelligible 
speech,  and  the  delusions  leave  no  doubt  that  we  are  not  dealing  with 
neurasthenia. 

Spinal  neurasthenia  manifests  itself  by  pain  and  tenderness  of  the 
spine,  intercostal  neuralgia,  aching  pain  in  the  legs,  numbness  and 
tingling  in  the  extremities,  some  defect  of  co-ordination,  as  shown  in 
the  gait  and  in  writing,  and  these "  symptoms  may  simulate  begmning 
locomotor  ataxia.  But  there  is  no  Argyll-Robertson  pupil,  there  are 
no  lightning-like  pains,  and  no  sensory  disorders,  for  the  sensation 
is  only  subjectively  disturbed,  and  the  reflexes  are  either  normal  or 
increased. 

There  may  be  much  difficulty  in  distinguishing  these  cases  of 
spinal  neurasthenia  from  those  of  so-called  nutritional  disease  of  the 
spinal  cord,  which  Gowers  has  specially  described.  The  symptoms, 
indeed,  are  the  same,  except  that  aching  in  the  back  and  legs  is  more 
pronounced ;  that  aching  in  the  legs  at  night  is  complained  of ;  that 
there  is  always  increased  knee-jerk ;  that  even  the  shortest  walks  pro- 
duce at  once  a  sense  of  fatigue  in  the  legs ;  that  these  show  some 
falling  off  in  nutrition ;  and  that  there  is  a  history  of  a  fall,  or  of  an 
acute  illness,  such  as  typhoid  fever  or  acute  rheumatism,  or  of  sexual 
excesses.  Then  the  general  neurasthenic  symptoms  are  absent  or  are 
not  marked. 

In  sexual  neurasthenia  there  is  great  irritability  of  the  sexual 
organs,  prostatorrhoea  and  spermatorrhoea  are  complained  of,  and 
tlieir  importance  immensely  exaggerated ;  there  is  pain  in  the  testi- 
cles, also  generally  greatly  exaggerated,  and  constant  dread  of  im- 


DISEASES  OF  THE   BRAIN   AND  SPINAL   CORD.  907 

potence.     In  women,  derangement  of  the  menstrual  function  is  not 
uncommon. 

The  diagnosis  of  neurasthenia  is  frequently  difficult,  as  we  have 
to  depend  so  much  upon  the  statements  of  the  patient.  Moreover,  it 
is  a  diagnosis  often  incorrectly  made  by  the  physician,  and  too  readily 
acquiesced  in  by  the  patient,  who  is  not  loath  to  believe  himself  the 
victim  of  "  nervous  prostration."  This  is,  indeed,  one  of  the  greatest 
of  difficulties ;  the  lazy,  the  irresolute,  the  self-indulgent  have  a  name 
under  which  they  dignify  their  failings,  or  shelter  their  shortcomings. 
Then  ill  health  associated  with  the  beginnings  of  organic  disease  in 
various  organs  is  very  apt  to  be  pronounced  neurasthenia.  No  diag- 
nosis of  this  ought  ever  to  be  made  until  after  the  closest  search 
for  a  structural  affection,  and  especially  for  lesions  in  the  nervous 
system,  kidneys,  stomach,  and  blood ;  a  large  number  of  cases  of 
so-called  neurasthenia  turn  out,  indeed,  to  be  a  disease  of  one  of 
these  parts.  Neurasthenia  is  most  apt  to  be  confounded  with  hysteria 
and  with  hypochondriasis,  and  what  makes  the  diagnosis  at  times  very 
perplexing  is  that  there  may  be-  an  association  of  the  morbid  states. 
In  hypochondriasis,  almost  exclusively  a  disease  of  males,  there  are 
actual  delusions  concerning  the  physical  state,  which  may,  however, 
be  very  good ;  not  so  in  neurasthenia,  though  there  is  often  great 
dread  of  disease.  The  paroxysms  of  hysteria,  its  peculiar  mental 
characteristics  of  exaggeration  and  deception,  the  emotional  disturb- 
ances, the  crises,  the  alterations  in  vision,  the  contractures,  the  anaes- 
thesias, the  hysterical  palsies,  and  the  great  range  of  hysterical  symp- 
toms distinguish  it. 

Diseases  characterized  by  Gradual  Impairnient  of  the 
Mental  Faculties  with  Paralysis. 

Chronic  Softening. — Softening  of  the  brain  may  be  caused  by 
nutritive  changes  consequent  upon  a  diseased  state  of  the  cerebral 
vessels,  or  by  an  inflammatory  disease  spreading  from  the  meninges 
to  the  brain,  or  taking  place  around  new  formations  and  old  lesions. 
It  may  also  follow  cerebral  hemorrhage.  But  its  chief  cause  is  occlu- 
sion of  the  cerebral  arteries  from  embolism.  In  rarer  instances  the 
plugging  is  due  to  a  thrombosis.  The  middle  cerebral  arteries  are 
the  most  common  site  of  the  emboli,  and  degeneration  and  softening 
occur  in  the  territories  supplied  by  the  obstructed  vessels.  What- 
ever the  cause  of  the  softening,  the  symptoms  are  much  the  same. 
They  are  briefly  these  :  gradual  impairment  of  intelligence  ;  weaken- 
ing of  memory ;  headache ;  vertigo  ;  muscular  debility ;  cutaneous 
hypersesthesia  or  anaesthesia ;  formication  and  numbness  ;  and  slight 


208  MEDICAL   DIAGNOSIS. 

or  partial  palsies,  pariicularly  of  the  muscles  of  one  side  of  the 
mouth,  or  of  one  eyelid.  Then  there  is  not  unfrequently  defective 
articulation,  with  great  u'ritability  of  temper,  nausea  and  vomiting, 
extreme  sensitiveness  to  sounds,  and  painful  feelings  in  various  parts 
of  the  body.  As  the  local  mischief  advances,  the  paralysis  becomes 
more  decided,  assuming  generally  the  hemiplegic  form  ;  and  spasms, 
either  tonic  or  clonic,  or  epileptic  convulsions,  occur. 

In  the  diagnosis  of  softening  the  most  important  pomt  is  .the 
recognition  of  the  state  that  has  led  to  it,  the  meningo-encephalitis, 
the  apoplexy,  the  diseased  blood-vessels,  or,  above  all,  the  embolism 
which  has  started  the  process  which,  in  place  of  an  acute  course,  is 
pursuing  that  of  a  slower  degeneration.  The  older  descriptions  of 
softening  are  very  fallacious.  Many  cases  of  cerebral  neurasthenia, 
many  of  general  paresis,  were  covered  by  this  term,  and  the  sec- 
ondary results  of  morbid  processes  in  the  brain  were  looked  upon 
as  the  prunar}^  disease. 

We  shall  next  inquire  how  such  cerebral  maladies  as  congestion, 
ansemia,  abscess,  and  atrophy  may  be  distinguished  from  softening. 

Congestion  is  discriminated  by  its  being  veiy  rarely  a  persistent 
state.  It  may  be  active  or  passive, — resulting  on  the  one  hand  from 
an  increased  supply  of  blood,  and  on  the  other  hand  from  interference 
with  the  venous  return.  An  acute  attack  produces  the  symptoms  of 
apoplexy ;  a  more  lasting  congestion  is  recognized  by  tracing  the 
cause  which  has  led  to  the  fulness  of  the  vessels, — such  as  a  disease 
of  the  heart  or  of  the  abdominal  viscera, — and  by  noting  that, 
although  the  patient  suffers  from  dull  headache,  from  disturbed  sleep, 
from  jerking  of  the  muscles,  from  pulsation  of  the  carotids,  from 
vertigo,  these  signs  are  far  from  constant,  and  come  and  go  for  a  long 
time  without  any  material  disturbance  of  the  functions  of  the  brain 
being  perceptible.  The  finding  of  optic  neuritis  or  choked  disk,  or 
the  presence  of  paralysis,  would  determine  against  congestion. 

Cerebral  ancemia,,  occurring  suddenly,  produces  unconsciousness, 
or  dizziness  or  stupor ;  or,  if  general,  convulsions.  When  more 
gradually  induced,  it  manifests  itself  by  drowsiness,  sighing  respira- 
tion, distressmg  headache,  often  referred  to  the  vertex ;  by  a  pale 
face  and  uninjected  eye  with  large  pupil ;  by  derangement  of  the 
special  senses ;  by  the  vertigo  and  the  other  symptoms  of  cerebral 
disorder  being  relieved  in  the  recumbent  position ;  and  by  a  feeble 
pulse  and  cool  forehead.'  Then,  in  tracing  its  history  we  are  apt  to 
find  that  it  occurs  in  those  who  have  been  exhausted  by  debilitating 
diseases,  or  by  repeated  hemorrhages,  or  by  albuminuria.  The  chief 
distinction  from  softening  lies  in  the  history  of  the  case  ;  the  aspect 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  209 

of  the  patient,  and  the  absence  of  palsies,  or  their  passing  nature, 
must  be  taken  into  account.  But  we  must  not  forget  that  antemia  is 
also  the  first  stage  of  softening  due  to  vascular  occlusion. 

Abscess  of  the  brain  arises  under  the  same  conditions  as  cerebritis ; 
but  pyogenic  micro-organisms  play  a  very  important  part  in  the  mor- 
bid process.  The  most  constant  clinical  association  is  with  disease  of 
the  ear ;  suppurating  processes  in  other  parts  of  the  body,  such  as  ab- 
scesses in  the  lungs  or  fetid  bronchitis,  are  also  not  infrequent  causes. 
The  symptoms  are  referable  in  part  to  the  inflammatory  process,  in 
part  to  the  presence  of  the  purulent  accumulation.  The  acute  cases 
get  progressively  worse  ;  in  cases  which  pursue  a  chronic  course  an 
initial  inflammatory  stage  of  brief  duration  is  succeeded  by  a  latent 
period,  sometimes  of  considerable  length,  and  this  in  turn  by  a  ter- 
minal stage,  ending  rapidly  in  death.  Among  the  early  symptoms 
are  headache  and  vomiting,  in  association  with  febrile  disturbance 
often  attended  with  chills.  Involvement  of  the  cortex  or  subjacent 
white  matter  may  cause  local  spasm ;  extensive  disease,  general  con- 
vulsions. Paralysis  and  delirium  may  be  also  present.  The  acute 
period  lasts  from  a  few  days  to  several  weeks.  In  the  latent  stage, 
which  may  continue  from  a  month  to  some  years,  decided  manifesta- 
tions may  be  wanting.  Often  there  is  headache ;  occasionally  there 
are  convulsions  ;  at  times  slight  mental  disturbance  exists.  Elevation 
of  temperature,  and  recurrent  rigors  followed  by  sweats,  also  happen 
in  abscess.  Optic  neuritis  is  as  often  absent  as  present.  Constant 
headache  and  vomiting  are  among  the  most  prominent  symptoms. 
Though  hemiplegia  is  met  with  not  unusually,  it  is  generally  slight. 
The  terminal  stage  which  marks  the  rupture  of  the  abscess  may  set 
in  abruptly  or  gradually,  with  increase  in  the  headache  and  mental 
symptoms,  with  vertigo,  vomiting,  derangement  of  consciousness, 
convulsions,  and  paralysis. 

Few  cases  of  abscess  of  the  brain,  as  Lebert^  has  shown,  last 
longer  than  eight  weeks.  Abscess  of  the  brain  may  be  latent,  and 
the  sudden  rupture  of  the  abscess  may  give  rise  to  symptoms  undis- 
tinguishable  from  those  of  hemorrhage,  undistinguishable  unless  we 
can  infer  an  abscess  from  a  disease  of  the  bones  of  the  head,  or  from 
some  points  in  the  history  of  the  case. 

Atrophy  of  the  brain  is  especially  observed  in  old  age,  and,  when 
marked,  may  be  the  cause  of  the  general  decay  of  cerebral  functions 
noticed  at  this  period  of  life.      It  is  very  generally  connected  with 


^  Archiv  fiir  Path.    Anat.,    Bd.   x.      See  also  GulTs  paper  in  Guy's   Hospital 
Reports,  3d  Series,  vol.  iii. 


210  MEDICAL  DIAGNOSIS. 

diffused  sclerosis.  As  a  rule,  it  occasions  no  distinctive  symptoms  ; 
it  has  been  specially  obsen^ed  in  idiots.  The  brain  is  sometimes 
midersized  trom  defective  development.  The  diminution  may  be 
general  or  unilateral,  or  even  circumscribed.  Partial  atrophy  is  a 
common  result  of  meningeal  hemorrhage  during  birth.  In  some  in- 
stances it  follows  meningitis  early  m  life.  Similar  processes  may  also 
take  place  during  intrauterine  existence.  These  varying  conditions 
give  rise  to  diverse  symptoms,  among  the  most  common  of  which  are 
mental  defect,  hemiplegia,  convulsions  and  mobile  spasm. 

The  differences  between  softening  and  cerebral  neurasthenia  have 
been  already  considered,  and  those  between  it  and  tumor  will  pres- 
ently engage  our  attention. 

Tumor. — Tumors  of  the  brain  give  rise  to  a  great  diversity  of 
signs,  according  to  their  locality,  their  size,  and  their  nature.  Let  us 
first  examine  the  symptoms  by  which  we  may  infer  their  existence. 

The  presence  of  a  tumor  in  the  brain  is  rendered  probable  if,  in 
addition  to  vertigo,  to  vomiting  or  to  a  disposition  to  vomit,  or  to  head- 
ache, violent,  but  paroxysmal  and  neuralgic  m  its  character,  we  find 
impairment  or  loss  of  vision,  or  indeed  of  any  special  sense,  and  epi- 
leptiform convulsions  not  followed  by  any  greater  deterioration  of 
health  than  previously  existed ;  if  with  these  signs  of  cerebral  irrita- 
tion the  intellect  is  not  at  first  markedly  disordered,  nor  the  articula- 
tion affected ;  and  if  paralyses  do  not  show  themselves  mitU  a  long 
time  after  the  headache,  and  are  even  then  limited  to  the  muscles  of 
the  eyeball  or  of  the  face,  or  to  the  muscles  of  the  extremities  of  one 
side  of  the  body.  As  a  further  sign  of  cerebral  tumor  we  may  class 
optic  neuritis  or  choked  disk.  It  is  a  curious  fact  to  be  borne  in 
mmd  that  cerebral  tumors  occur  in  males  more  than  twice  as  frequently 
as  in  females.  It  may  also  be  noted  that  the  larger  number  of  cases 
are  in  the  young  or  in  those  in  the  prime  of  life  ;  the  aged  are  re- 
markably exempt.  The  commonest  forms  of  tumor  are  tuberculous, 
gliomatous,  sarcomatous,  and  sjiDhilitic.  Less  common  are  carcino- 
mata  and  parasitic  tumors.  Before  the  evidence  of  a  tumor  is  con- 
sidered conclusive  we  must  exclude  other  chronic  cerebral  maladies, 
especially  softening,  abscesses,  and  chronic  meningitis. 

We  separate  chronic  softening  by  noticing  that  the  headache  caused 
by  a  tumor  is  much  more  constant  and  violent,  having  paroxysmal 
exacerbations  :  that  the  intelligence  remains  for  a  long  time  intact, 
save,  perhaps,  in  a  weakening  of  the  memory  ;  that  optic  neuritis  is  a 
usual  accompaniment ;  that  motor  and  sensory  disturbances  are  less 
frequent  and  prominent,  but  convulsions  far  more  so.  Further,  cere- 
bral tumor  is  more  common  in  early  life,  chronic  softening  in  late  life. 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  211 

Disease  of  the  heart  or  of  the  blood-vessels,  or  Bright's  disease,  or, 
especially,  the' history  of  an  embolic  seizure,  points  to  the  latter  state. 
Remissions,  or  intervals  of  apparent  improvement,  occur  in  both 
morbid  conditions  ;  but  they  are  more  perfect  and  of  longer  duration 
in  tumor  than  in  softening. 

The  differential  diagnosis  between  tumor  and  abscess  is  more 
difficult.  We  may  conclude  the  latter  to  exist,  if  the  cephalalgia  be 
sudden  in  its  development,  and  uniform  and  general,  instead  of  neu- 
ralgic and  limited.  Then  epileptic  convulsions,  drowsiness,  paralysis 
and  coma  succeed  one  another  much  more  rapidly  and,  except  convul- 
sions, are  present  much  more  constantly  in  abscess  than  in  tumor, — 
indeed,  epileptic  fits  are  about  as  often  absent  as  present.^  Further, 
optic  neuritis  and  localizmg  symptoms  are  more  common  in  tumor 
than  in  abscess,  and  this  shows  especially  in  the  palsies  of  cranial 
nerves.  If,  moreover,  we  obtain  the  history  of  injury  to  the  skull,  or 
find  a  discharge  from  the  ear,  or  pain  upon  pressure  over  the  mastoid 
process,  or  a  chronic  disease  about  the  head,  or  protracted  suppuration 
in  any  part  of  the  body,  we  may  safely  infer  that  an  abscess,  not  a 
tumor,  is  the  cause  of  the  evident  cerebral  mischief.  Abscess,  like 
tumor,  chiefly  affects  males. 

Chronic  meningitis,  an  affection  sometimes  complicating  tumor,  is 
discriminated  by  laying  stress  on  its  etiological  relations, — such  as 
blows  upon  the  head,  diseases  of  the  cranial  bones,  syphilis,  rheuma- 
tism, alcoholism,  chronic  tuberculosis, — and  by  observing  its  frequent 
though  irregular  accessions  of  fever,  the  great  irritability  of  temper, 
the  dulness  of  intellect,  the  loss  of  memory,  and  the  nocturnal  de- 
lirium. The  pain,  too,  is  duller  and  more  diffused  than  in  tumor,  and 
there  is  more  vertigo.  The  locahzing  symptoms  are  not  so  definite 
and  fixed,  nor  the  convulsions  as  distinctly  epileptiform  in  type.  Yet 
convulsive  movements  of  some  muscles  are  common,  and  may  be 
even  followed  by  incomplete  paralysis.  Meningitis  may  be  excluded  if 
optic  neuritis  or  any  marked  alteration  of  the  disks  be  found  early  in 
the  case.  Indeed,  optic  neuritis  is  absent  or  is  very  slight  m  chronic 
meningitis.  Yet  the  diagnosis  is  often  very  difficult,  especially  between 
tumor  and  syphilitic  or  protracted  tubercular  meningitis. 

Thrombosis  of  the  sinuses  of  the  brain  may  occasion  partial  palsies,  . 
with  symptoms  of  cerebral  pressure,  like  those  of  tumor,  and  cannot 
be  distinguished  except  in  the  instances  in  which  we  find  distention 
of  the  collateral  circulation  shown  in  the  fulness  of  the  veins  of  the 

^  Thus,  they  occurred  in  only  thirty-eight  cases  of  abscess  of  the  brain  out  of 
seventy-thi'ee  collected  by  Gull  and  Sutton  (Reynolds's  System  of  Medicine). 


212  MEDICAL  DIAGNOSIS. 

nose,  temple,  and  forehead,  and  injection  and  oedema  of  the  forehead 
and  eyelids.  Convulsions,  further,  are  very  rarely  among  the  symp- 
toms ;  and  generally  these  are  more  similar  to  the  manifestations  of 
meningitis  than  of  tumor ;  coma  is  not  uncommon.  When  primary, 
the  condition  is  usually  a  result  of  enfeeblement  of  the  circulation  and 
altered  blood  state  in  exhausting  or  wasting  diseases,  especially  those 
of  infancy  and  old  age.  In  children  with  marasmus,  or  in  adults  with 
caries  of  the  skull,  or  purulent  ear  disease,  marked  cerebral  phenom- 
ena may  lead  to  the  correct  inference  of  thrombosis.  Secondarj^ 
thrombosis  is  most  often  met  with  as  an  infective  process  from  adja- 
cent disease,  especially  chronic  suppurative  disease  of  the  ear,  and 
there  is  local  oedema  and  tenderness  over  the  mastoid  and  internal 
jugular.  Portions  of  the  disintegrating  thrombus  may  be  carried  into 
different  parts  of  the  body,  and  embolic  phenomena  appear.  In  the 
marasmic  cases  the  symptoms  are  often  those  of  the  hydrocephaloid 
disease  of  Marshall  Hall,  with  which  it  may  be  associated  ;  hemorrhage 
into  the  cortex  of  the  brain  is  common. 

The  precise  seat  of  the  tumor  is  difficult  to  determine.  An  affec- 
tion of  the  special  senses  or  of  cranial  nerves  points  to  disease  near 
to,  or  at,  the  base  of  the  brain ;  and  the  probability  of  this  view  is 
much  strengthened  if  there  be  paralysis  of  the  face  on  the  side  oppo- 
site to  that  of  the  extremities,  and  if  vigorous  inspiration,  during 
which  the  brain  falls  and  presses  the  morbid  mass  against  the  walls 
of  the  base  of  the  skull,  cause  or  increase  pain ;  whereas,  so  says 
R.omberg,  in  tumors  on  the  upper  surface,  forced  expiration  produces 
a  like  result.  In  cases  of  tumor  of  the  'pons  or  the  crus,  particularly 
when  tubercular,  incoordination  of  the  arm  similar  to  the  jerky  move- 
ment of  disseminated  sclerosis  is  met  with ;  but  it  is  unilateral,  not 
bilateral  as  in  sclerosis.  In  tumors  of  the  cerebellum  we  have  head- 
ache, severe  vomiting,  nystagmus,  staggering  gait,  spasms,  and  rigidity  ; 
the  kuee-jerk  may  be  absent  or  increased ;  there  may  be  no  marked 
alteration  of  the  optic  disks,  or,  as  de  Schweinitz  has  pointed  out,  the 
appearances  may  be  those  usually  regarded  as  indicative  of  albu- 
minuric retinitis.  Tumors  in  or  near  the  cortex  of  the  brain  give  rise 
to  localized  convulsions  on  the  opposite  side  of  the  body.  In  tumors 
of  the  frontal  lobes  there  are  marked  psychical  symptoms  :  and  ataxia, 
such  as  we  observe  in  cerebellar  disease,  is,  Bruns  has  proved,  a  very 
significant  symptom.  In  tumors  of  the  Rolandic  region  monospasm 
and  unilateral  spasm  precede  or  attend  the  increasing  paralysis.  In 
determining  the  exact  position  of  brain  tumors  we  must  make  use 
of  the  researches  on  the  localization  of  the  cerebral  functions.  The 
difficulty  of  applying   this    extending   knowledge  to  the   diagnosis  of 


DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD.  213 

tumors  at  the  bedside  is,  that  they  may  give  rise  to  circumscribed  in- 
flammation around  them,  or  to  irritation  in  even  more  remote  parts, 
and  that  the  special  manifestations  of  the  disorder  of  the  part  affected 
by  the  tumor  are  thus  blurred  or  obscured.  Then  we  must  also  bear 
in  mind  that  several  tumors  may  be  present. 

In  endeavoring  to  determine  the  seat  of  the  tumor  it  is  necessary 
to  distinguish  as  clearly  as  possible  the  difference  between  the  results 
of  generalized  pressure  or  chstant  effects,  and  those  due  to  direct  and 
localized  influences.  It  is  only  the  constant  abnormal  symptom  that 
points  out  the  location  of  the  lesion.  Paralyses,  pareses,  spasms, 
which  change  in  intensity  or  affect  now  one,  now  another  set  of  mus- 
cles or  organs,  show  that  the  centres  are  disordered  only  indirectly 
and  temporarily,  and  that  the  true  position  of  the  neoplasm  is  to  be 
sought  elsewhere.  Another  indication  is  derived  from  a  consideration 
of  the  relative  intensity  of  the  different  symptoms.  The  less  com- 
plete a  paralysis,  or  the  less  energetic  the  spasm  of  a  certain  set  of 
muscles,  the  less  certain  is  the  injury  to  be  localized  in  their  centres, 
and  the  reverse.  Too  much  dependence  must  not  be  placed  on  the 
subjective  location  of  the  pain.  Diffuse  pressure  may  cause  more 
pain  at  a  point  far  removed  from  the  growth  than  its  immediate 
neighborhood.  But  when  spasm  or  paralysis  of  a  limited  set  of 
muscles  exists,  as  in  cortical  epilepsy,  and  the  pain  is  located  by  the 
patient  at  a  point  corresponding  to  the  topographical  position  of  the 
corresponding  centres,  the  deduction  becomes  quite  certain  that  the 
lesion  is  at  this  point.  When  from  other  indications  the  inference  is 
probable  that  the  growth  is  in  the  cortical  substance,  the  additional 
symptom  of  pain  makes  the  diagnosis  more  sure. 

It  is  manifest  that  in  all  tumors  of  the  cortex,  or  of  the  white  sub- 
stance immediately  beneath,  the  symptoms  will  be  unilateral  and  in- 
clude convulsions.  When  both  sides  of  the  body  are  about  equally 
affected,  the  tumor  must  be  placed  at  the  base  of  the  brain,  unless 
the  growths  be  multiple  and  situated  in  symmetrical  parts  of  the  two 
hemispheres.  Where  the  symptoms  are  more  intense  upon  one  side 
of  the  body  than  upon  the  other,  the  weaker  symptoms  are  to  be 
attributed  to  the  distant  or  indirect  effects  of  pressure.  Paralysis,  of 
course,  is  a  symptom  of  more  profound  disturbance  than  spasm  or 
convulsive  movement.  The  last  is  therefore  probably  due  to  an  irri- 
tative or  indirect  effect,  or  to  a  slowly  growing  neoplasm.  The  exist- 
ence of  ixipillitk^  optic  neuritiH,  or  choked  disk,  is  in  a  suspected  case 
of  tumor  among  the  most  conclusive  signs  of  intracranial  neoplasm. 
But,  unfortunately,  it  gives  scarcely  an  indication  either  of  the  nature 
or  of  the  seat  of  the  new  growth.     Yet  since  the  papillitis  may  precede 


214  MEDICAL   DIAGNOSIS. 

other  symptoms,  since  also  no  deterioration  of  vision  may  have  been 
noticed  by  the  patient,  a  careful  opthalmoscopic  examination  should 
always  be  made  when  there  is  any  thought  of  the  existence  of  tumor. 

Can  we  form  an ,  opinion  of  the  nature  of  a  tumor  of  the  brain 
from  any  of  the  signs  referable  to  the  cerebral  malady  ?  We  cannot : 
the  character  of  the  pain  has  been  thought  to  be  of  great  significance  ; 
but  the  testimony  to  prove  that  it  is  so  is  in  the  highest  degree  un- 
satisfactory. We  may  sometimes,  however,  from  the  history  of  the 
case,  or  from  the  existence  of  some  of  the  manifestations  of  special 
cachexia,  draw  a  correct  inference.  In  gliomatom  brain  tumors, 
Virchow  has  pointed  out,  there  is  often  the  liistory  of  a  blow.  They 
are  usually  single,  and  most  common  in  the  cerebral  hemispheres, 
and  occur  next  in  frequency  in  the  cerebellar  hemisphere  ;  then  in  the 
central  ganglia,  pons,  medulla,  crus,  and  corpora  quadrigemina.  Gli- 
omata  are  comparatively  frequent  in  children.  Sarcomata  develop  in 
the  brain  or  in  the  membranes,  or  from  the  bones,  particularly  at  the 
base.  They  differ  from  gliomata  in  being  circumscribed  and  not  in- 
filtrating. Tuberculous  growths  are  often  multiple  and  most  frequent 
in  the  cerebellum ;  they  are  also  found  in  the  pons,  central  ganglia, 
crus,  medulla,  and  corpora  quadrigemina. 

If  we  find  disease  of  the  lungs,  or  any  evidences  of  scrofula,  and 
the  patient  be  young,  we  shall  probably  be  right  in  conjecturing  the 
tumor  of  the  brain  to  be  a  mass  of  tubercle ;  but  if  the  sufferer  be 
advanced  in  years,  and  exhibit  tumors  in  various  parts  of  the  body, 
or  other  signs  of  a  cancerous  diathesis,  we  may  with  reasonable  cer- 
tainty presume  the  tumor  within  the  skull  to  be  cancerous.  Syphilitic 
tumors  are  mostly  cortical,  rarely  cerebellar,  grow  rapidly,  and  are 
greatly  influenced  by  antisyphilitic  treatment.  Other  kinds  of  tumors 
and  deposits  can  scarcely  be  said  to  be  within  the  reach  of  diagnosis. 
Cysts  seated  in  the  superficial  portions  of  the  brain  either  occasion  no 
symptoms  or  give  rise  to  headache,  to  attacks  of  vertigo,  to  vomitmg, 
and  to  epileptic  seizures,  but  very  rarely  to  palsies.  The  symptoms 
mentioned  are  far  more  apt  to  be  present  when  the  cysts  occupy  the 
lateral  ventricles ;  then  epileptic  convulsions  are  rarely  absent. 

The  manifestations  of  an  aneurism  within  the  cranium  are  those 
of  an  ordinary  tumor,  and  the  affection  is  not  distinguishable  except 
when  the  symptoms  are  referable  to  the  presence  of  a  tumor  in  the 
course  of  a  cerebral  vessel,  and  we  find  present  a  cause  of  aneurism, 
such  as  syphilis  or  chronic  endocarditis  with  vegetations,  or  decided 
indications  of  disease  of  the  vessels  in  other  parts  of  the  system.^ 

^  James  H.  Hutchinson,  Pennsylvania  Hospital  Reports,  vol.  ii. 


DISEASES  OF  THE  BBAIN   AND  SPINAL   CORD.  215 

A  small  aneurism  may  occasion  no  symptoms ;  one  large  enough  to 
exert  pressure  on  adjacent  structures  may  be  attended  with  head- 
ache, often  pulsating,  usually  continuous,  sometimes  paroxysmal ; 
vertigo ;  mental  dulness  and  irritability ;  occasionally  convulsions ; 
paralysis  ;  bilateral  hemianopsia  ;  ^  rarely  optic  neuritis.  Neither  the 
presence  nor  the  absence  of  a  subjective  feehng  of  pulsation  and  of  a 
murmur,  whether  in  the  carotids  or  the  vertebral  or  the  basilar  arteries, 
and  audible  on  auscultation  of  the  skull,  has  a  positive  significance  ; 
for,  notwithstanding  the  cases  of  Jonathan  Hutchinson  ^  and  Humble,^ 
in  which  the  diagnosis  was  made  during  life,  'the  detection  of  a  mur- 
mur, as  I  know  from  observation,  is  not  a  certain  sign.  A  murmur, 
moreover,  is  not  uncommon  in  rickets.  Even  a  pulsating  tumor  pro- 
truding through  the  skull  may  not  be  due  to  an  aneurism,  but  be 
caused  by  a  glioma,  as  in  the  case  mentioned  by  Mills.^ 

Aneurism  of  the  internal  carotid  artery  may  cause  blindness  on 
the  same  side,  paralysis  of  the  third,  and  of  the  ophthalmic  division  of 
the  fifth,  nerve,  impairment  of  the  sense  of  smell,  and  hemiplegia. 
Aneurism  of  the  anterior  cerebral  may  occasion  many  of  the  same 
symptoms,  although  the  muscles  of  the  eyebah  usually  escape. 
Aneurism  of  the  middle  cerebral  is  usually  attended  with  hemiplegia 
and  convulsions.  Aneurism  of  the  basilar  artery  causes  extensive 
damage,  with  widespread  paralysis,  including  the  cranial  nerves  ;  con- 
vulsions are  rare. 

General  Paralysis. — This  fatal  cerebral  malady,  known  also  as 
general  paresis  and  dementia  paralytica,  is  the  result  of  a  diffuse  in- 
terstitial meningo-encephalitis  ;  the  spinal  cord  may  become  second- 
arily affected.  Clinically,  the  disorder  is  marked  by  impairment  of 
the  powers  of  locomotion  ;  by  an  inability  to  articulate  distinctly, — 
a  symptom  which  precedes  the  deranged  locomotion ;  by  the  expres- 
sionless countenance  ;  and  by  failure  of  memory  and  complete  per- 
version of  the  mental  faculties,  amounting,  in  fact,  to  insanity. 

The  palsy  is  peculiar :  indeed,  except  towards  the  end,  there  is,  in 
the  usual  sense  of  the  term,  no  palsy  in  the  limbs  at  all ;  there  is 
rather  a  want  of  control  over  their  co-ordinate  action,  displaying  itself 
first  in  the  hands  by  clumsiness  of  movements  and  irregular  hand- 
writing, and*  in  the  gait  by  uncertainty  and  a  swaying  from  side  to 
side  when  the  patient  attempts-  to  walk.  The  impairment  of  the 
muscular  movement  gradually  extends  :  tremulousness  in  the  muscles 

^  Case  of  Mitchell  and  Dercum,  Nervous  Diseases  by  American  Authors,  1895. 

^  British  Medical  Journal,  April,  1875. 

■■'  London  Lancet,  Oct.  1875. 

^  The  Nervous  System  and  its  Diseases,  1898. 


216  ■  MEDICAL  DIAGNOSIS. 

of  expression  is  noticed ;  the  speech  becomes  more  inarticulate,  until 
scarcely  a  word  can  be  distinguished ;  and  the  patient  cannot  rise 
without  being  assisted.  The  reflexes  are  not  uniformly  affected  ;  the 
knee-jerk  is  often  exaggerated,  but  in  some  cases  reflex  contraction 
of  the  tendo  Achillis  is  wanting.  As  the  disease  advances,  the  cuta- 
neous sensibility  is  greatly  diminished  or  is  lost.  The  pupils  are  un- 
equal, generally  contracted  and  sluggish.  The  mental  derangement 
is  often  manifested  by  an  exaggerated  sense  of  personal  power  or 
importance,  and  fancies  of  great  wealth ;  the  moral  feelings  greatly 
deteriorate ;  sometimes  there  are  maniacal  outbreaks  and  epileptic 
attacks,  or  alternating  periods  of  excitement  and  depression.  Decep- 
tive remissions  in  the  progress  of  the  disease  may  take  place,  but  the 
termination  is  invariably  fatal.  Death  is  often  preceded  by  convulsive 
attacks  and  by  coma,  or  by  painful  contractions  of  the  muscles  of  the 
trunk  or  the  extremities,  or  by  obstinate  diarrhoea,  or  by  pulmonary 
affections.     Pneumonia  is  especially  common.^ 

The  early  signs  of  general  paralysis  of  the  insane  are  difficult  to 
recognize.  A  change  in  character,  in  moral  sense,  in  power  of  men- 
tal attention,  and  in  judgment,  absent-mindedness,  and  weariness 
easily  brought  on  by  brain-work  or  by  any  physical  exertion,  are 
very  significant  in  a  middle-aged  man,  if  joined  to  alteration  in 
handwriting  and  some  impairment  in  executing  delicate  muscular 
movements.  With  these  symptoms  there  is  commonly,  as  Folsom^ 
mentions,  loss  of  flesh. 

In  more  advanced  stages  there  is  not  much  doubt  about  the 
malady.  It  differs  from  other  forms  of  extensive  general  paralysis 
in  being  far  less  of  a  real  palsy.  It  is  certainly  far  less  complete 
than  the  extensive  paralyses  which  follow  lesions  of  the  upper  portion 
of  the  spinal  cord,  or  which  are  consequent  upon  the  poison  of  lead, 
or  of  malaria,  or  of  diphtheria.  Its  association  with  marked  disturb- 
ance of  the  intellect  and  its  psychic  symptoms  furnish,  moreover,  a 
difl'erential  test  of  great  value,  and  not  merely  with  reference  to  the 
general  palsies  just  mentioned,  but  also  as  regards  neurasthenia,  the 
trembling  movements  of  old  age,  of  progressive  muscular  atrophy, 
and  of  chronic  alcoholism.  In  one  of  its  forms,  as  Westphal  points 
out,  there  is  a  strong  resemblance  to  locomotor  ataxia"  in  the  signs 
of  disturbed  co-ordination,  sensory  impairment  and  absence  of  knee- 
jerk,  with  incontinence  of  urine  ;  but  the  tremor  in  the  muscles  of 
the  lips  and  face  and  the  perverted  mental  state  become  of  greatest 

'  Crichton  Browne,  Brain,  Oct.  1883. 

■^  Transactions  of  Association  of  Ameiican  Physicians,  1889. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  217 

significance.  In  some  cases,  moreover,  changes  in  the  posterior  and 
lateral  columns  of  the  cord  have  been  found  after  death,  in  addition 
to  those  present  in  the  brain.  On  the  other  hand,  the  ataxia  and  the 
palsies  distinguish  the  disease  from  mere  senile  dementia.  Then,  too, 
general  paresis  is  a  disease  of  early  manhood  and  of  middle  age,  and 
follows  syphihs,  mental  overstrain  and  anxiety,  alcoholism,  or  sexual 
excesses. 

The  defect  in  the  articulation  and  the  attending  tremor  of  the  lips, 
and  in  some  mstances  the  occurrence  of  apoplectiform  seizures, 
accompanied  by  considerable  elevation  of  temperature,  may  cause 
the  disease  to  be  mistaken  for  cerebrospinal  sclerosis.  But  in  this 
affection,  while  the  embarrassed,  scanning  speech  coexists  with  great 
helplessness  of  manner,  with  oscillation  of  the  eyeballs,  with  tremor 
manifesting  itself  only  on  emotion,  with  paresis  of  the  lower  limbs, 
and  finally  with  permanent  contractions,  we  do  not  notice  decided 
alienation  of  mind ;  there  is  nothing  more  than  general  enfeeblement 
and  blunted  emotional  faculties. 

Paralysis  agitans  may  be  confounded  with  general  paralysis  of  the 
insane.  But  in  paralysis  agitans  the  voice  is  not  really  tremulous ; 
there  is  rather  a  monotonous  tone  and  uncertain  utterance,  which, 
with  the  fixed  features,  the  sensation  of  excessive  heat,  the  peculiar 
gait  and  attitude,  the  unaltered  cutaneous  sensibility,  the  tremor  ever 
present  except  during  sleep,  and  the  very  long  duration  of  the  symp- 
toms, characterize  the  disease.  The  intellect  becomes  obscured 
towards  the  end  of  the  malady,  but  not  before. 

Diseases  characterized  by  Enlargement  of  the  Head. 

Chronic  Hydrocephalus. — The  signs  of  dropsy  of  the  brain  are 
progressive  enlargement  of  the  head,  and  a  perversion  or  a  gradual 
loss  of  one  or  several  of  the  special  senses,  of  the  mental  faculties, 
and  of  the  power  of  voluntary  motion.  The  child  cannot  bear  the 
weight  of  the  head  ;  the  gait  is  tottering  and  uncertain.  The  intellect, 
slowly  but  certainly,  becomes  deranged.  As  the  malady  advances, 
strabismus,  partial  palsies,  epileptic  convulsions,  vomiting,  cutaneous 
anaesthesia,  and  loss  of  sight,  of  smell,  and  of  taste  are  observable  ; 
the  bowels  become  very  constipated ;  and  a  copious  secretion  of  tears 
and  of  saliva  is  not  infrequent. 

Before  death  takes  place,  which  sometimes  does  not  happen  for 
years,  the  child  ordinarily  becomes  idiotic.  A  few  cases  recover ; 
fewer  reach  adult  age  with  the  brain  compressed  by  the  accumu- 
lated fluid ;  in  still  fewer  the  disease  does  not  develop  until  after  child- 
hood.    If  the  patient  survive  until  adult  age,  the  size  of  the  skull  is 

14 


218  MEDICAL   DIAGA^OSIS. 

generally  immense.  I  saw,  some  years  since,  a  young  man,  twenty- 
two  years  of  age,  whose  head  measured  fully  two  feet  and  a  half  in 
circumference.  He  could  walk  unaided,  but  often  fell.  He  was  half 
idiotic,  and  subject  to  epileptic  fits  ;  yet  he  had  sufficient  intelligence 
to  understand  what  was  said  to  him,  and  in  his  childish  way  to  do  as 
he  was  told. 

Hydrocephalus  may  result  from  meningitis,  from  interference  with 
the  circulation  through  the  veins  of  Galen,  or  from  obstruction  to  the 
free  movement  of  the  cerebro-spinal  fluid ;  occasionally  no  causative 
condition  can  be  recognized. 

The  skull  is  sometimes  very  large  without  dropsy  of  the  brain 
existing.  The  cranial  bones  may  slowly  thicken  to  an  extraordinary 
degree  from  sj^philis,  or  from  unknown  causes.  The  head  may  be 
overgrown,  and  its  bones  thickened  and  spongy,  as  in  rhachitis ;  or  it 
may  be  large  when  there  is  no  disease.  These  states  differ  from 
chronic  hydrocephalus  by  the  absence  of  cerebral  symptoms ;  and  in 
doubtful  cases  we  may  resort  to  the  ophthalmoscope  as  a  means  of 
diagnosis.  The  vessels  of  the  eye,  even  in  the  early  stages  of  chronic 
hydrocephalus,  enlarge,  and  in  proportion  as  the  serum  compresses 
the  brain  we  find  an  increase  of  vascularity  in  the  retina,  with  dilata- 
tion of  its  veins,  and  ^^ith  an  increase  of  the  number  of  its  vessels ; 
complete  or  partial  serous  infiltration  of  the  retina ;  and  an  atrophy, 
more  or  less  perceptible,  of  the  optic  nerve.  These  lesions  varj'"  with 
the  age  of  the  disease  and  the  amount  of  serous  effusion  ;  but  none 
of  them  exist  in  rickets.  Then  in  rickets  the  tendency  is  to  spasm 
of  the  glottis,  to  diarrhoea, — and  the  head  is  rather  square-shaped 
than  globular.  In  very  rare  instances  the  size  of  the  head  has  been 
obsen^ed  to  be  increased  in  the  cerebral  palsies  of  children  due  to 
hemorrhage  or  embolism. 

Hypertrophy  of  the  Brain. — It  is  very  questionable  whether 
such  a  disease  as  a  true  hypertrophy  of  the  brain  exists.  The  enlarge- 
ment, when  not  due  to  an  unrecognized  hydrocephalus,  is  mostly  a 
congenital  malformation,  or  is  found  in  children  in  connection  with 
rickets,  with  changes  in  the  bram  of  a  sclerotic  kind,  or  with  those 
alterations  caused  by  a  defect  of  bram  substance  to  wliich  the  name 
porencephalus  has  been  given,  but  where,  at  the  same  tune,  in  other 
portions  of  the  brain  extensive  cell  infiltrations  and  connective  tissue 
changes  may  happen.  It  is  stated  that,  in  hypertrophy  of  the  brain, 
unlike  hydrocephalus,  when  the  fontanelles  are  touched,  the  sensation 
is  that  of  a  solid  substance. 


DISEASES  OF  THE   BRAIN  AND  SPINAL   CORD.  219 

Diseases  characterized  by  Enlargement  of  Various  Parts. 

Acromegalia. — In  this  peculiar  and  uncommon  affection,  first 
described  by  Marie,  enlargement  of  the  hands  and  feet  occurs,  as 
well  as  of  the  head,  and  especially  of  the  face.  Often  bones  and  soft 
tissues  both  take  part  in  the  change,  although  the  muscles  may  un- 
dergo wasting,  with  resulting  weakness.  The  hands  become  broad 
and  spade-like  ;  the  face  assumes  the  shape  of  an  elongated  oval ; 
the  jaws,  the  malar  bones,  and  the  supraorbital  arches  are  promi- 
nent;  the  forehead  is  receding.  Spinal  curvature  is  common.  The 
disease  occurs  in  young  adults  and  pursues  a  chronic  course  ;  in  rare 
instances  it  has  been  met  with  in  children,  especially  in  imbeciles. 
Changes  in  the  pituitary  body  are  constant ;  in  some  cases  a  tumor 
has  been  present,  and  in  these  headache,  optic  neuritis,  and  visual 
derangement  have  been  observed.  Somnolence,  headache,  and 
atrophy  of  the  optic  nerve  are  frequent.  Sometimes  changes  in  the 
thyroid  gland  have  been  noted,  either  enlargement  or  diminution  in 
size.  Occasionally  dulness  on  percussion  over  the  upper  portion  of 
the  sternum  has  existed,  and  this  has  been  attributed  to  persist- 
ence of  the  thymus  gland.  Rheumatic  or  neuralgic  pains  are  not  in- 
frequent ;  and  the  tongue,  lips,  and  nose  may  show  striking  increase 
in  size,  while  the  nails  are  small  in  proportion  to  the  great  growth  of 
the  bones  in  the  hands  and  feet.  Acromegalia  may  affect  only  one 
side  of  the  body. 

In  gigantism  there  is  symmetrical  growth  of  all  the  bones  and 
parts  of  the  body,  but  there  are  neither  ocular  nor  cerebral  symptoms. 
Nor  are  there  in  leontiasis,  in  which  the  enlarged  face  is  said  to  re- 
semble that  of  a  lion. 

In  myxoedema  the  tumefaction  is  not  confined  to  the  extremities, 
but  is  very  general,  and  depends  not  upon  changes  in  the  bones,  but 
upon  a  peculiar  infiltration  of  the  connective  tissues.  The  skin  is 
thickened  and  adherent  to  the  subjacent  tissues,  and  not  pliable  as  in 
acromegalia.  The  face  is  "  moon-shaped,"  and  the  jaws  and  malar 
bones  are  not  projecting. 

In  the  condition  known  as  osteitis  deformans^  or  Pagefs  disease,  tlie 
changes  in  the  bones  of  the  face  give  to  this  the  appearance  of  an  in- 
verted triangle.  Besides,  the  disease  attacks  the  long  bones  of  the 
body,  which  undergo  deformity ;  the  spine  curves  ;  the  face  is  not  in- 
volved. 

Certain  chronic  diseases  of  the  lungs  and  pleura  are  attended 
with  enlargement  of  the  terminal  phalanges  of  the  fingers  and  toes, 
and  of  the  distal  epiphyses  of  the  bones  of  the  legs  and  forearms. 


220  MEDICAL  DIAGNOSIS. 

The  finger-nails  are  curved,  and  tlie  vertebral  column  is  often  bent. 
The  changes  are,  however,  usually  restricted  to  these  parts,  and  the 
disorder  is  not  likely  to  be  mistaken  for  acromegalia. 

Diseases  characterized  by  Paroxysmal  Pain. 

There  is  a  group  of  nervous  disorders  characterized  solely  by  pain, 
confined  ordinarily  to  one  nerve.  These  nervous  pams  bear  the  ge- 
neric name  of  neuralgia.  Indeed,  in  all  neuralgias  the  chief  symptoms 
of  the  disorder  resolve  themselves  into  one  symptom, — the  symptom 
of  pain.  The  pains  are  acute,  follow  the  course  of  a  nerve-branch, 
and  come  on  in  paroxysms  having  distinct  exacerbations,  succeeded 
by  distinct  intermissions.  In  some  cases  these  intermissions  are  long, 
in  others  short ;  m  some  they  are  complete,  m  others  the  pain  is  last- 
ing and  becomes  from  time  to  time  exalted, — rather  remissions,  there- 
fore, than  intermissions.  When  the  pain  is  severe  it  may  be  attended 
with  muscular  twitcMng.  Sometmies,  too,  there  is  pallor  followed  by 
redness  and  swelling,  though  swelling  is  rare.  Tenderness  is  present 
only  when  the  neuralgia  is  of  long  continuance ;  at  least  there  is  not 
tenderness  along  the  aclung  nerve,  though  we  may  find  certain  sensi- 
tive spots,  as  where  a  ner^'^e-trunk  emerges  from  a  bony  canal,  or 
passes  over  a  hard  surface,  or  through  fascia  to  become  superficial,  or 
at  the  point  of  division  of  a  nerve-trunk,  or  of  anastomosis  of  two 
nerve-trunks. 

The  pain  of  neuralgia  is  of  a  purely  nervous  character,  and  exists 
independently  of  inflammation,  or  of  any  recognizable  textural  change 
of  the  nerve-centres  or  nerve-trunks.  Fixed  pain  and  jDersistent  early 
tenderness,  evidences  of  lessened  sensibility  and  of  trophic  changes 
in  the  skin  or  muscles,  and  cutaneous  eruptions  in  the  course  of  the 
affected  nerve,  bespeak  neuritis,  and  not  neuralgia.  Indeed,  it  is  only 
when,  after  a  minute  search,  we  can  detect  no  definite  organic  cause 
for  the  local  pain,  that  we  may  conclude  that  our  patient  is  lalDoring 
under  neuralgia.  Among  other  points  of  difference,  too,  we  observe 
that  the  pain  of  neuralgia  is  often  relieved  by  deep  pressure,  while 
that  of  neuritis  is  thus  increased,  as  it  is  by  movement :  that  it  m- 
termits  much  more  completely :  and  that  in  neuritis  we  often  have  the 
history  of  contusion  or  strain,  or  of  extension  of  inflammation  from 
parts  near  by.  Changes  m  the  hair  may  take  place  as  the  consecjuence 
of  either  neuritis  or  of  neuralgia. 

From  the  characteristics  of  the  pain  just  mentioned,  it  is  evident 
that  it  is  not  likely  to  be  confounded  with  that  of  ordinary  local  in- 
flammation. But  there  is  a  kind  of  local  pain  for  which  neuralgia  is 
often  mistaken  :  the  pain  of  subacute  or  of  chronic  rheumatism.     Yet 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  221 

this  is  ill  reality  very  dissimilar.  The  rheumatic  pain  is  attended 
with  soreness,  is  aggravated  by  movement  or  by  pressure,  is  more 
diffuse  and  irregular,  much  more  constant,  much  more  influenced  by 
alternations  of  temperature,  but  not  acute  or  paroxysmal,  and  not 
limited  anatomically  to  the  course  of  a  nerve,  but  scattered  over 
parts  supphed  by  several.  In  studying  the  relations  of  rheumatism 
to  localized  pain  we  must  bear  in  mind  that  exposure  to  cold  is  also 
a  frequent  cause  of  neuritis,  which  then  appears  to  have  a  rheumatic 
origin.  Except  as  regards  the  influence  of  weather,  the  pain  of  myalgia 
presents  much  the  same  points  of  difference  as  the  pain  of  rheuma- 
tism, in  addition  often  to  the  history  of  a  muscular  strain. 

The  source  of  the  neuralgia  should  always  be  determined  as 
closely  as  possible,  on  account  both  of  the  prognosis  and  of  the  treat- 
ment. In  many  cases  it  will  be  found  to  be  connected  with  anaemia ; 
in  others,  with  the  poison  of  rheumatism,  of  lithaemia  or  gout,  of 
malaria,  of  syphilis,  or  of  uraemia  or  ptomaines,  or  to  be  due  to  in- 
juries to  nerves  by  contusion  or  wounds.  It  may  be  owing  to  emo- 
tional disturbances,  to  neurasthenia,  or  to  exposure  to  cold.  It  is 
often  reflex,  the  pain  being  far  away  from  the  seat  of  the  disease. 
For  instance,  an  affection  of  the  digestive  apparatus,  of  the  liver,  or 
of  the  kidneys,  may  give  rise  to  neuralgia  in  parts  quite  remote  from 
them. 

Neuralgia  may  occur  in  any  portion  of  the  body.  It  may  shift 
i'apidly  from  one  part  to  another,  as  in  that  peculiar  neuralgia  de- 
scribed by  Putegnat,^  excited  by  a  desire  to  pass  water  and  by  the 
act  of  micturition,  beginning  with  numbness  and  acute  burning  or 
lancinating  pain  along  the  urinary  passages,  then  affecting  particularly 
the  nerves  of  the  forearm,  especially  the  ulnar,  and  disappearing 
completely  after  micturition.  The  most  frequent  seat  of  neuralgia  is 
about  the  head ;  and  we  shall  here  notice  chiefly  a  few  of  its  most 
common  kinds.  The  other  varieties  of  the  disorder  will  be  elsewhere 
alluded  to. 

Facial  Neuralgia. — The  sensory  branches  of  the  fifth  pair  are 
often  the  site  of  agonizing  pain.  But  all  the  branches  of  the  nerve 
are  not  equally  liable :  the  lowermost  of  them  is  rarely  affected. 
When  the  supraorbital  division  is  the  seat  of  the  ailment,  the  pain 
shoots  to  the  forehead,  the  eyebrow,  and  the  eyeball,  which  is  apt  to 
become  mjected.  There  are  tender  points  just  above  the  supra- 
orbital notch  or  foramen,  in  the  outer  part  of  the  upper  eyelid,  at  the 
lower  edge  of  the  nasal  bone,  and  sometimes  within  the  eyeball.     If 

1  Gazette  Hebdom.  de  Med.  et  de  Chir.,  April,  1864. 


222  MEDICAL  DIAGNOSIS. 

the  infraorbital  nerve  be  disturbed,  the  pain  darts  to  the.  upper  hp, 
to  the  upper  row  of  teeth  and  the  posterior  nares,  and  the  cheek 
reddens  and  tingles,  or  the  eyelids  twitch.  Tender  points  are  found 
at  the  infraorbital  foramen,  at  the  side  of  the  nose,  over  the  malar 
bone,  and  on  the  gums  of  the  upper  jaw.  When  the  pain  occurs  in 
the  inferior  branch,  it  radiates  to  the  lower  lip  and  the  chin,  and  is 
frequently  accompanied  by  a  flow  of  saliva.  Tenderness  exists  at 
the  inferior  dental  foramen,  on  the  temple,  and  over  the  parietal  emi- 
nence. Sometimes  only  one,  at  other  times  two,  at  other  times  all 
of  the  branches  of  the  fifth  are  implicated  in  the  complaint,  or  they 
may  be  seized  upon  alternately.  There  is  often  also  pain  at  the 
vertex. 

The  disease  is  one  of  those  belonging  to  advancing  years  ;  one  of 
the  neuralgias  of  bodily  decay  on  which  Anstie  dwells.  It  has  the 
same  general  causes  as  any  other  form  of  neuralgia.  Sometimes  it  is 
associated  with  decayed  teeth,  or  with  an  abnormal  state  of  the  bones 
of  the  head  or  face,  such  as  thickening  of  the  frontal,  ethmoid,  and 
sphenoid  bones.  Many  of  these  cases  terminate,  after  months  or 
years  of  excruciating  agony,  in  apoplexy.^  When  from  decayed 
teeth,  the  pain  Anally  localizes  itself  in  the  dental  arch,  and  there  is 
persistent  discomfort  in  addition  to  the  neuralgic  exacerbations.^ 

The  intervals  between  the  paroxysms  of  neuralgia  are  of  varying 
length.  They  may  be  of  six  months',  or  even  a  year's,  duration  ;  but 
so  long  an  intermission  is  uncommon.  Sudden  changes  of  weather 
generally  excite  attacks. 

The  malady  is  easily  recognized.  The  pain  from  disease  of  the 
bones  of  the  face  may  be  mistaken  for  it.  But  this  pain  is  not 
paroxysmal.  Painful  ancesthesia  of  the  fifth  nerve  is  discriminated  by 
the  insensibility  of  the  painful  portions  to  touch,  or  indeed  to  any 
irritation.  Spasm  of  the  face  is  distinguished  by  the  absence  of  pain 
from  the  convulsive  twitchings  of  reflex  origin  which  sometimes  take 
place  in  facial  neuralgia  or  "  tic  douloureux." 

The  epileptiform  neuralgia  described  by  Trousseau  is  dissimilar  in 
these  peculiarities  :  whether  simple  or  combined  with  rapid  convulsive 
movements  of  the  muscles  on  one  side  of  the  face,  it  is  quickly  over ; 
it  lasts  but  ten  or  twenty  seconds  at  a  time,  never  more  than  a  min- 
ute. Yet  during  the  short  duration  of  the  seizures  the  pain  reaches 
an  intensity  greater  than  in  ordinary  neuralgia.     Moreover,  in  some 

^  Sir  Henry  Halford's  Essays  and  Orations,  p.  37  et  seq. 

^  An  interesting  collection  of  cases  is  given  in  an  essay  by  Brubaker  on  Reflex 
Neurosis  associated  with  Dental  Pathology. 


DISEASES  OF  THE  BRAIN  AND  SPINAL   CORD.  223 

persons  who  suffer  from  this  terrible  malady — the  attacks  of  which 
may  happen  in  quick  succession  by  day  as  well  as  by  night,  and  then 
perhaps  remit  for  weeks  or  months — vertiginous  sensations  or  epilep- 
tic fits  occur,  and  thus  the  diagnosis  is  facilitated  by  the  history  of 
the  case. 

Hemicrania. — The  pain  here  is  hmited  to  one  side  of  the  head, 
but  it  may  extend  to  the  other  side,  and  be  bilateral.  It  is  intensified 
by  sound  of  any  kind,  by  movement  and  by  light,  and  is  often  pre- 
ceded by  disorder  of  sight,^  sometimes  of  hearing  and  taste,  by 
numbness  and  tingling  in  the  limbs,  by  transient  aphasia,  by  a  sense 
of  weight,  though  rarely  by  muscular  weakness.  Nausea  generally 
attends  the  headache,  but  is  most  pronounced  when  this  has  reached 
its  height,  and  is,  as  a  rule,  followed  by  vomiting  or  retching;  the 
nausea  and  vomiting  of  the  "  sick-headache"  are  usually,  indeed, 
prominent  features  of  the  paroxysm,  hardly  less  prominent  than  the 
pain.  During  the  attack  there  is  commonly  pallor  of  the  face,  which 
at  the  close  gives  place  to  flushing ;  slight  mental  change  may  also  be 
noticeable.  The  attack  lasts  for  hours  or  days  ;  often  it  is  severe  for 
half  a  day.  It  may  end  with  free  diaphoresis  or  diuresis.  At  its 
termination,  the  patient  feels  exhausted,  yet  soon  recovers  his  usual 
health,  and  may  remain  free  from  a  seizure  for  a  long  time.  But,  as 
the  disorder  commonly  happens  in  women  at  their  menstrual  periods, 
the  interval  is  not  apt  to  extend  beyond  four  weeks.  At  times  the 
sensory  phenomena  of  migraine  occur  without  headache. 

Hemicrania,  migraine,  or  megrim,  has  been  explained  as  a  neurosis 
of  the  sympathetic  ;  or  as  a  discharge  of  nerve-force,  a  "  nerve-storm," 
from  centric  disorder.  It  is  a  stubborn  affection,  the  tendency  to  which 
diminishes  after  middle  age,  but  which,  as  Liveing^  clearly  demon- 
strates, has  an  hereditary  character. 

Hemicrania  must  be  carefully  separated  from  the  pain  in  the  head 
that  accompanies  an  organic  cerebral  affection.  The  main  points  of 
distinction  are,  that  the  neuralgic  malady  is  paroxysmal,  is  attended 
with  the  same  group  of  symptoms  during  each  attack,  and  produces 
no  nervous  derangement  in  the  intervals  between  the  seizures. 

Rheumatism  of  the  scalp  differs  from  hemicrania  in  the  pain  being 
continuous,  dull,  and  superficial ;  in  occupying  generally  both  sides  of 
the  head ;  in  being  augmented  by  moving  the  affected  muscles,  and 

^  There  may  be-  obliteration  of  objects  in  the  field  of  view,  or  a  curious  glim- 
mering attended  with  colored  outline  near  the  outside  corner  of  the  field  of  vision. 
These  ophthalmic  migraines  have  been  described  by  Charcot  (vol.  iii.  of  his 
Clinical  Lectures)  as  being  at  times  among  the  forerunners  of  general  paralysis. 

2  On  Megrim,  London,  1873. 


224  MEDICAL  DIAGNOSIS. 

relieved  by  warmth.  Moreover,  there  is  almost  always  other  evidence 
of  rheumatism,  and  the  pain  is  intensified  by  pressure ;  whereas  in 
hemicrania,  although  the  hair  may  be  sensitive  to  the  touch,  strong 
pressure  on  the  forehead,  and  even  on  the  hairy  part  of  the  scalp,  does 
not  increase  the  pain,  may,  indeed,  afford  relief. 

In  pe7Hostitis  affecting  the  bones  of  the  head,  particularly  when 
syphilitic,  we  may  find  the  same  violent  pain  as  in  hemicrania.  But 
there  is  considerable  tenderness  on  pressure,  the  parts  attacked  are 
swollen  and  less  elastic  than  the  healthy  portions,  and  the  pain  is 
especially  severe  at  night. 

Sciatica. — This  is  sometimes  a  neuralgia  following  the  course  of 
the  sciatic  nerve,  but  often  it  is  a  neuritis.  The  seat  of  the  greatest 
suffering  is  generally  the  lateral  surface  of  the  thigh  ;  thence  the 
pains  extend  to  the  popliteal  space,  and  in  some  instances  along  the 
anterior  part  of  the  leg.  Often,  too,  the  patient  complains  of  an 
aching  near  the  sciatic  notch  and  in  the  loins.  The  pain  is  more  or 
less  steady ;  but  it  has  its  periods  of  fierce  exacerbation,  and  damp, 
cold,  and  pressure  augment  it.  When  the  nerve  is  inflamed  there  is 
tenderness  on  pressure  over  the  course  of  the  nerve.  Pressure  on 
localized  points  always  develops  pain,  and  the  points  that  are  most 
marked  are  on  the  lower  end  of  the  sacrum,  on  the  side  of  the 
trochanter  opposite  the  emergence  of  the  great  and  small  sciatic 
nerves,  various  points  on  the  posterior  aspect  of  the  thigh,  one  at  the 
head  of  the  fibula,  and  one  behind  the  outer  ankle. 

The  disease  is  obstinate,  and  lasts  for  weeks  or  months.  It  in- 
terferes with  locomotion,  because  of  the  distress  which  movements 
of  the  leg  and  foot  occasion.  It  is  much  more  frequent  in  men  than 
in  women,  and  is  a  very  rare  disease  in  children.  Generally  it  de- 
pends upon  exposure  to  cold,  or  upon  the  rheumatic  diathesis,  or 
upon  a  neuralgic  predisposition,  or  upon  an  irritation  affecting  the 
nerve  before  it  leaves  the  pelvis,  the  result  not  unusually  of  sexual 
disorder,  or  of  pressure  from  a  gravid  womb,  or  from  an  accumula- 
tion of  faeces  in  the  lower  bowel.  In  many  instances  it  is  connected 
with  gout,  in  others  with  anaemia,  with  syphilis,  with  disease  of  the 
hip-joints,  and  it  may  be,  although  it  .very  rarely  is,  symptomatic  of 
cerebral  disease.  Occasionally  it  is  due  to  reflex  excitation  of  the 
nerve.  Sometimes  it  occurs  after  forced  marches  or  long  rides ; 
probably  in  many  of  these  cases,  however,  the  sciatica  is  rheumatic. 
It  is  seldom  double,  except  when  of  diabetic  origin,  or  when  due  to 
compression  from  a  growing  tumor  in  the  pelvis  or  from  enlarging 
cancerous  vertebrae. 

Sciatica,  when  of  long  duration,  leads  to  loss  of  motor  power  in 


DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD.  225 

the  leg,  to  tingling,  and  to  anaesthesia ;  and  certain  nutritive  changes 
are  observed  in  the  limb,  which  is  found  to  have  dwindled,  or  there 
may  be  oedema.  When  the  disorder  is  the  result  of  neuritis,  there  is 
generally  decided  and  persistent  tenderness, — in  pure  neuralgia  there 
is  not  much, — and  movement  and  position  have  marked  influence  on 
the  pain.  Further,  the  history  of  the  case  in  pure  neuralgia,  the 
spontaneous  pain,  the  usual  anaemia,  and  the  previous  occurrence 
of,  or  the  coexistence  with,  other  neuralgias,  are  very  significant. 
Occasionally  the  neuritis  ascends  to  the  cord. 

An  effusion  within  the  sheath  of  the  nerve  may,  according  to 
Fuller,  be  inferred  when  a  patient  who  is  suffering  from  sciatica  com- 
plains of  a  dull  aching  or  a  benumbing  pain  in  the  limb,  causing 
it  to  feel  swollen,  and  when  this  sense  of  numbness  and  increased 
bulk  has  succeeded  to  pain  of  greater  intensity,  accompanied  by 
cramps  and  startings  and  more  or  less  inability  to  move  the  limb. 

The  disorders  which  are  most  likely  to  be  confounded  with  sciatica 
are :  rheumatism  of  the  muscles  and  fibrous  sheaths  around  the  hip- 
joint ;  affections  of  the  joint;  and  pains  caused  by  irritation  of  the 
kidney.  The  first  i-s  very  readily  distinguished.  It  is  generally,  what 
sciatica  is  rarely,  double-sided ;  and  the  pain  is  dull,  diffuse,  not 
paroxysmal',  not  limited  to  the  sciatic  nerve  and  its  area  of  distribu- 
tion, nor  as  much  increased  on  pressure  as  that  of  sciatica.  But, 
practically  speaking,  this  kind  of  rheumatism  is  seldom  seen  unless 
associated  with  rheumatic  inflammation  of  the  sciatic  nerve. 
-  In  affections  of  the  hip-joint  the  suffering  is  increased  by  standing 
with  the  weight  of  the  body  thrown  on  the  diseased  leg.  Moreover, 
the  pain  does  not  descend  in  the  course  of  the  sciatic  ;  is  not  associated 
with  tenderness  of  the  nerve ;  the  aspect  of  the  limb  points  to  the 
disorganization  that  is  going  on  ;  the  leg  shortens.  Yet,  before  ad- 
mitting this  as  a  mark  of  difference,  it  must  be  ascertained  by  careful 
measurement ;  for,  in  consecjuence  of  muscular  contractions,  the 
affected  limb  in  sciatica  may  appear  to  be  shorter  than  it  is.  The 
main  points  of  distinction  between  sciatica  and  a  nervous  affection  of 
the  hip-joint  are  the  usual  combination  of  the  latter  with  hysteria, 
the  very  superficial  tenderness,  and  the  fact  that  the  pain  is  apt  to  ex- 
tend over  the  whole  thigh. 

Irritation  of  the  kidney  causes  pain  shooting  down  the  thigh.  The 
distress  exists,  however,  in  the  course  of  the  anterior  crural  nerve,  is 
therefore  not  localized  in  the  sciatic,  is  unassociated  with  tenderness, 
but  is  accompanied  by  a  frequent  desire  to  pass  water,  and  by  other 
signs  of  disorder  of  the  urinary  function. 

Sciatica  is  sometimes /ei^i'^iec/',  especially  by  soldiers.     But  the  copy 


226  MEDICAL  DIAGNOSIS. 

is  rarely  a  very  accurate  one.  Impostors  complain  of  pain  on  press- 
ure and  on  motion,  but  are  ignorant  that  the  pain  is  prone  to  exacer- 
bate after  intervals  of  comparative  quiet,  and  to  increase  in  violence 
as  night  approaches.  Their  fancied  torment  is  constant,  but  does 
not  prevent  them  from  sleeping  ;  they  wince  when  the  muscles  of 
the  thigh  are  touched,  yet,  if  their  attention  be  diverted,  the  hand 
may  be  pressed  along  the  sciatic  nerve  without  any  sign  of  tenderness 
being  manifested. 

General  Crural  Neuritis. — In  this  disease,  much  rarer  than 
sciatica,  there  is  extensive  inflammation  of  the  fibrous  sheaths  cov- 
ering the  lumbar  and  sacral  plexus  ;  in  consequence  many  of  the 
nerves  of  the  leg  are  involved  at  their  origin,  and  there  are  signs  of 
widespread  neuritis.  There  is  pain  along  the  course  of  several 
nerves,  and  motion  is  somewhat  impaired,  and  there  may  be  mus- 
cular atrophy ;  the  tenderness  of  the  nerve-trunks  is  most  apt  to  be 
found  near  the  pelvis,  and  this  is  an  important  sign  as  distinguishing 
the  complaint  from  disease  of  the  spinal  cord.  The  pain  is  sometimes 
reflected  to  the  sound  side.  The  knee-jerk  is  usually  increased.  The 
disease  occurs  mainly  in  gouty  or  rheumatic  persons,  and  is  apt  to  be 
of  considerable  duration.  It  may  affect  pre-eminently  a  single  nerve, 
as  the  anterior  crural ;  and  the  sensory  phenomena,  especially  anaes- 
thesia on  the  front  of  the  thigh,  are  then  very  marked. 

Brachial  Neuritis. — This  is  a  rare  and  very  perplexing  form  of 
neuritis  ;  more  strictly  speaking,  it  is  usually  a  perineuritis, — a  pri- 
mary inflammation  of  the  sheaths  of  the  branches  that  form  the 
brachial  plexus.  It  is  a  disease  of  the  latter  part  of  life,  met  with 
chiefly  in  the  rheumatic  or  gouty.  The  pain  is  very  great,  and  comes 
on  in  paroxysms  ;  but,  irrespective  of  these,  a  dull  pain  or  ache  is 
constantly  present.  The  pain  has  its  seat  above  the  cla^dcle,  in  the 
axilla,  in  the  region  of  the  scapula,  and  the  inner  part  of  the  shoulder- 
joint.  It  lancinates  to  the  neck  and  chest,  and  sometimes  along  the 
course  of  the  arm,  giving  rise  there  to  a  sense  of  weight  and  heat. 
Motion  will  induce  the  pain,  even  walking  may.  There  is  sensitive- 
ness of  the  skin  near  the  afl'ected  part,  and  flal^biness  and  slight 
wasting  of  groups  of  muscles,  which  may  even  prevent  the  reaction 
of  degeneration ;  over  the  atrophied  muscles  anaesthesia  is  at  times 
met  with.  There  may  be  persistent  tenderness  of  the  nerves  near 
their  origin,  but  this  is  no.t  always  easy  to  determine ;  the  influence  of 
movement  in  evoking  pain  is  always  striking  and  almost  immediate. 

During  the  paroxysms  of  pain,  which  are  most  apt  to  come  on  in 
the  latter  part  of  the  day,  when  fatigued,  there  is  a  sense  of  constric- 
tion at  the  upper  part  of  the  chest  with  some  shortness  of  breathing, 


DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD.  227 

and  in  consequence  the  disease,  when  left-sided, — and  it  happens  that 
all  the  cases  I  have  seen  have  been  so, — is  apt  to  be  mistaken  for 
angina  pectoris.  This  occurs  the  more  readily  since  both  affections 
are  diseases  of  advancing  years,  and  there  may  be  coincident  degen- 
erative changes  in  heart  or  arteries ;  and  irregular  heart  action  is  not 
an  unusual  attendant.  The  great  difference,  besides  the  exact  seat  of 
pain,  is  that  in  brachial  neuritis  some  pain  or  tenderness  is  always 
present,  and  always  intensified  by  movement,  and  that  we  do  not  have 
the  rapid  appearance  and  disappearance  of  the  agonizing  paroxysms 
that  distinguish  angina ;  the  local  changes  in  the  muscles  in  brachial 
neuritis  are  also  of  value.  These,  too,  help  us,  in  addition  to  the  per- 
sistent tenderness  and  the  influence  of  motion  on  the  parts,  in  distin- 
guishing the  cases  of  pure  brachial  neuralgia  from  brachial  neuritis. 
In  some  instances,  in  place  of  rheumatism  or  gout  causing  the  neuritis, 
we  observe  it  after  contusions  or  dislocations  of  the  shoulder,  or  from 
the  pressure- of  enlarged  glands  or  tumors.  In  any  case,  owing  chiefly 
to  the  constancy  with  which  the  arm  is  kept  c[uiet,  fixity  of  joint  and 
arthritic  changes  may  supervene. 

There  is  a  form  of  rheumatism  in  which  the  interstitial  tissue  of 
the  nerves  and  muscles  is  affected,  to  which  Gowers  has  given  the 
name  of  neuromyositis.,  which  very  closely  resembles  brachial  neuritis, 
with  which,  indeed,  it  may  be  combined.  Here  the  mere  expec- 
tation of  movement  produces  pain,  as  do  passive  movements  and 
compression  of  the  nerve-endings  by  voluntary  contractions  ;  the 
muscles  are  tender,  and  the  joints,  usually  the  shoulder-joint,  may 
become  fixed  and  the  seat  of  adhesions,  and  add  to  the  rigidity  and 
the  inhibition  of  movement.  The  pam  in  neuromyositis  is  altogether 
connected  with  motion  or  the  expectation  of  motion,  and  there  are 
no  paroxysms  of  spontaneous  pain,  as  is  so  marked  a  feature  of 
brachial  neuritis. 


CHAPTER   IIJ. 

DISEASES   OF   THE   UPPER   AIR-PASSAGES. 
SECTION   I. 

DISEASES    OF    THE    NOSE    AND    ASSOCIATE    ORGANS. 

The  nasal  chambers,  pharynx,  larynx,  and  trachea  constitute  the 
upper  air-passages.  As  the  disorders  of  the  nose  and  the  naso- 
pharynx, or  the  space  between  the  plane  of  the  posterior  nares  and 
a  horizontal  line  drawn  through  the  lower  end  of  the  soft  palate,  be- 
long largely  to  a  class  which  requires  surgical  treatment,  a  brief  review 
will  be  given  m  this  place  of  those  only  that  have  features  of  medical 
interest.  The  frontal  sinuses  are  in  direct  connection  with  the  nasal 
chambers,  and,  in  case  of  occlusion  of  their  normal  outlet,  there  is  an 
accumulation  of  secretion,  which  may  cause  headache.  This  is  likely 
to  occur  especially  in  the  catarrhal  inflammation  attending  influenza,  in 
which  the  headache  may  contmue  for  weeks  until  the  inflammation 
subsides,  or  the  patency  of  the  outlet  is  restored.  The  headache  may 
be  associated  with  vertigo.  Tumors  may  develop  from  the  mucous 
membrane  lining  the  frontal  sinuses,  of  the  same  character  as  those  of 
the  nasal  chambers  ;  and  the  larvse  of  insects,  or  mature  forms,  such 
as  centipedes,  find  their  way  at  times  into  these  cavities  and  there 
cause  pain  and  irritation. 

Frontal  sinus  diseases  are  to  be  distinguished  from  supraorbital 
neuralgia^  migraine,  and  cerebral  disease  by  careful  inspection  of  the 
interior  of  the  nose,  by  examination  with  the  curved  probe  to  test  the 
openness  of  the  canal,  by  the  presence  of  tenderness  and  other  local 
signs  of  inflammation,  such  as  swelling  or  discoloration,  and  by  the 
history  of  the  case. 

The  affections  of  the  antrum  Highmorianum,  or  maxillary  sinus,  are 
similar  to  those  of  the  frontal  sinuses,  and  are  more  surgical  than 
medical.  Many  of  these  cases  are  attended  by  a  pain  above  the  corre- 
sponding eye,  and  may  be  mistaken  for  migraine  and  the  neuralgia  of 
frontal  sinus  disease. 

The  diseases  of  the  nasal  chambers  may  be  divided  into  acute 
and  chronic.  Among  the  former  are  coryza,  acute  rhinitis,  hay-fever, 
hemorrhage  or  epistaxis,  hydrorrhoea,  mycosis,  and  abscess.     Promi- 

228 


DISEASES  OF  THE  NOSE  AND  ASSOCIATE  OEGANS.     229 

nent  among  the  second  class  are  rhinitis,  hypertrophic  and  atrophic, 
cirrhosis  of  the  mucous  membrane,  ethmoiclitis,  thickening  and  devia- 
tion of  the  septum,  rhinoscleroma,  new  growths,  specific  destruction 
by  tuberculosis,  syphilis,  lupus,  and  malignant  disease. 

Another  division  might  be  made  into  local  affections  and  those 
occurring  in  eruptive  fevers  and  other  acute  diseases.  For  instance, 
in  scarlatina,  smallpox,  typhoid  fever,  and  diphtheria,  swelling  with 
increase  of  secretion  and  ulceration  may  occur,  while  in  rheumatism 
and  influenza  peculiar  changes  are  noted.  Many,  probably  most,  of 
the  instances  of  marked  deviation  of  the  septum  and  associated  ab- 
normalities are  not  evidences  of  disease,  but  are  due  >  to  former 
fractures  with  unreduced  dislocation,  or  to  heredity.  Bryson  Dela- 
van  has  found  asymmetry  in  the  nasal  chambers  to  be  the  rule  rather 
than  the  exception. 

As  regards  affections  of  the  nose  attended  by  mucous  or  purulent 
discharge  and  more  or  less  obstructed  breathing,  it  is  well  to  bear  in 
mind  the  possibility  in  children  of  there  being  a  foreign  body  in  the 
nose,  and  in  older  patients  rhinoliths  are  sometimes  detected  upon 
rhinoscopic  examination.  In  one  remarkable  case  described  by  War- 
ren,^ the  breech-pin  of  a  gun  was  discovered  embedded  in  the  right 
nasal  fossa,  where  it  had  been  driven  by  the  explosion  of  a  gun,  several 
months  previously,  and  its  presence  in  the  nose  had  not  been  suspected. 

Coryza,  or  acute  catarrh,  is  a  general  affection,  which  manifests 
itself  by  inflammation  of  the  mucous  membranes  of  the  nose  es- 
pecially, but  other  mucous  surfaces  of  the  air-passages  may  be  previ- 
ously or  subsequently  affected.  It  often  follows  exposure  to  cold  and 
dampness,  and  attacks  those  principally  of  lowered  vitality.  Rhinitis 
may  be  due  to  local  irritation,  as  rough  manipulation,  operations  upon 
the  nose,  or  strong  appHcations.  It  may  be  confined  to  one  nostril. 
Upon  inspection,  the  mucous  surface  is  of  a  bright  red  color  in  cer- 
tain locations,  the  turbinated  erectile  tissue  is  engorged,  shows  abra- 
sions, and  bleeds  readily.  The  fossa  may  be  obstructed  to  a  greater 
or  less  degree  by  inflammatory  swelling  of  the  mucous  membrane, 
and  the  secretions  vary  in  density  from  a  clear  serous  fluid  to  a  caseous 
or  fibrinous  exudation.  To  the  latter  the  names  of  rhinitis  caseosa 
and  rhinitis  jibrinosa  have  been  applied.  Cases  with  marked  oedema 
have  been  reported  under  the  title- of  rhinitis  cedematosa? 

Dij)htheria  of  the  nose  may  occur  independently,  but  is  usually  a 
concomitant  or  sequel  of  faucial  diphtheria.     At  the  present  day  the 


^  Surgical  Ol-jservations,  Boston,  1867. 

2  J.  C.  Mulhall,  Trans.  Am.  Laryng.  Assoc,  1893. 


230  MEDICAL  DIAGNOSIS. 

presence  of  the  Klebs-Loeffler  bacillus  is  relied  upon  to  decide  the 
diagnosis  of  diphtheria,  although  this  micro-organism  has  occasionally 
been  found  in  affections  of  the  throat  and  nose,  which  give  no  clinical 
evidence  of  being  diphtheritic,  and  it  is  present  in  many  cases  with 
purulent  discharge  from  the  nose.  An  acute  catarrh  is  sometimes 
an  early  symptom  of  some  specific  disease,  of  measles,  for  instance. 
Nasal  catarrh  accompanies  erysipelas  and  influenza.  Nasal  catarrh 
may  be  also  produced  by  the  administration  of  remedies,  as  of  the 
iodides,  or,  by  the  mhalation  of  drugs,  such  as  ipecacuanha.  At  cer- 
tain times  of  the  year,  when  the  air  is  filled  with  pollen  from  the 
artemisia  absinthifolium,  or  ragweed,  the  ailanthus  tree,  or  from  roses 
or  grasses,  many  persons  suffer  from  what  is  called  hay-fever,  hay- 
asthma,  rose-cold  or  hyperaesthetic  rhinitis,  which  has  for  its  most 
marked  sign  the  reappearance  of  the  symptoms  upon  the  same  day 
each  year,  suggesting  a  strong  neurotic  element,  Daly,  Roe,  and 
Sajous  have  shown  the  dependence  of  many  of  these  cases  upon 
nasal  abnormalities.  A  severe  purulent  rhinitis  of  acute  form  may 
be  caused  by  accidental  gonorrhoeal  infection  of  the  nose;  the  history 
of  the  case  gives  the  explanation,  and  the  discovery  of  the  gonococcus 
the  demonstration. 

Nasal  hydrorrhcea  is  distinguished  from  coryza  by  the  excessive 
flow  of  a  serous  fluid  from  the  mucous  membranes,  especially  over 
the  turbinated  bodies,  which  are  pale  and  sodden.  The  affection  is 
unilateral,  but  it  may  be  bilateral.  Unlike  hay-fever,  it  happens  at 
all  seasons,  though,  like  hay-fever,  it  is  found  in  neurotic  subjects.  It 
may  occur  in  paralysis  of  the  trifacial  nerve,  or  as  a  result  of  head 
injury,  and  may  be  associated  with  polypi,  or  myxoma  of  the  nose ; 
it  is  at  times  of  months'  duration.^  Arteriosclerosis  affecting  the 
vessels  of  the  mucous  membrane  of  the  nose  is  evidenced  by  a  special 
disposition  to  coryza  and  pharyngeal  catarrh,  with  local  congestions 
and  tendency  to  nosebleed.  Such  patients  are  especially  liable  to 
obstruction  of  the  nasal  passages  by  temporary  swellings  wliich  are 
followed  by  free  effusion  of  watery  secretion.^  In  cerebrospinal 
rhinorrhoea  there  is  constant  dripping  from  the  nose  of  a  fluid  of  specific 
gravity  about  1005  from  which  mucus  and  proteids  are  absent,  and 
which  on  boiling  reduces  Fehling's  solution.^ 

Nasal  hemorrhage  may  indicate  a  general  condition  of  the  vascular 

^  As  in  a  case  reported  by  C.  E.  Bean  before  the  Laryngological  Association 
in  1891. 

^  James  T.  Wliittaker,  Pennsylvania  Medical  Journal,  Feb.  1899,  p.  459. 
^  St.  Clair  Thomson  on  Cerebro-Spinal  Rhinorrhcea,  1899. 


DISEASES  OF  THE  NOSE  AND  ASSOCIATE  ORGANS.     231 

system,  a  degeneration  of  the  arterial  coats,  with  or  without  increased 
tension.  Occurring  after  the  middle  period  of  life,  in  a  person  other- 
wise apparently  healthy,  it  suggests  the  likelihood  of  apoplexy  or  con- 
tracted kidney.  It  is  important  to  distinguish  between  those  cases  in 
which  the  blood  only  passes  through  the  nose,  and  those  in  which  the 
blood  comes  from  the  nose.  A  rhinoscopic  examination,  both  anterior 
and  posterior,  is  essential  to  an  exact  diagnosis.  In  nasal  hemorrhage 
the  blood  very  frequently  comes  from  the  septum  low  down,  where  it 
can  be  easily  inspected. 

Post-nasal  catarrh  has  for  its  prominent  symptoms  the  dropping  of 
mucus  from  the  soft  palate  into  the  throat,  and  the  expulsion,  usually 
in  the  morning,  of  masses  of  gelatinous  mucus  or  of  hardened  crusts 
from  the  naso-pharynx,  giving  rise  to  the  unpleasant  habit  of  hawking 
and  spitting.  In  such  cases  rhinoscopic  examination  reveals  inflam- 
mation of  the  mucous  membrane  in  the  vault  of  the  pharynx,  and 
the  glandular  tissue,  or  so-called  "  pharyngeal  tonsil,"  may  be  hyper- 
trophied  and  form  polypoid  excrescences,  or  large  adenoid  tumors 
that  may  entirely  occlude  the  posterior  nasal  openings.  Digital  ex- 
ploration is  a  valuable  means  of  diagnosis,  especially  in  children. 
Deafness  may  be  caused  by  occlusion  of  the  Eustachian  tubes,  and 
mouth-breathing  is  a  necessary  sequence.  Snoring,  dryness  of  the 
throat,  and  night-terrors  occurring  in  children,  may  also  be  due  to 
this  condition.  A  form  of  post-nasal  catarrh,  of  less  severity,  attends 
posterior  hypertrophies  and  other  abnormalities  of  the  nose  attended 
by  increase  of  secretion.     The  diagnosis  is  made  by  rhinoscopy. 

In  glanders  the  purulent  or  sanious  discharge  from  the  nose  is  at- 
tended with  erysipelatous  blush  on  the  nose  and  cheeks,  characteristic 
pustules  on  the  face  and  in  the  nasal  passages,  and  the  symptoms  of 
pyaemia. 

The  chronic  forms  of  rhinitis  accompanied  by  catarrhal  thickening 
of  the  septum  or  of  the  turbinate  bodies,  atrophy  or  cirrhosis  of  the 
mucous  membrane,  and  the  development  of  cysts,  polypi,  or  papillary 
fibromata,  are  recognized  by  careful  rhinoscopic  examination,  and 
belong  to  surgery  rather  than  to  medicine.  In  former  times  ozaena 
was  regarded  as  a  disease,  but  it  now  is  recognized  as  ah  attendant 
upon  chronic  atrophic  rhinitis,  in  which  the  secretions  dry  into  crusts 
which  undergo  putrefactive  changes,  and  thus  produce  the  offensive 
odor.  In  cirrhosis  there  are  contraction  of  the  mucous  membrane 
and  evidences  of  atrophy,  without  decided  catarrhal  symptoms,  thus 
showing  a  constitutional  origin.  Hypertrophy  of  the  mucous  mem- 
brane is  considered  as  a  preliminary  stage  to  atrophy ;  and  the  pro- 
duction of  polypi,  or  of  myxoma,  or,  more  rarely,  of  fibroma,  is  not 


232  MEDICAL  DIAGNOSIS. 

an  uncommon  result.  Hypertrophies  are  distinguished  from  new 
growths  by  their  situation,  color,  density,  and  immobility  ;  new  growths 
being  in  abnormal  situations,  of  peculiar  color,  and  pedunculated  ;  for 
instance,  polypi  are  white  and  glistening,  cysts  are  white,  paptilloma 
may  look  like  a  small  bunch  of  grapes.  The  diagnosis  of  papillary 
hypertrophy  from  true  papilloma,  papillary  fibroma,  depends  upon  its 
location,  appearance,  and  the  microscopic  details,  which  also  distin- 
guish the  latter  from  epithelioma  and  sarcoma.  Abscess  most  fre- 
quently appears  in  the  septum,  when  it  occurs  in  the  nose. 

In  making  the  diagnosis  between  benign  and  malignant  growths, 
the  rapid  development  and  general  appearances  of  the  latter  are 
usually  depended  upon  as  conclusive.  At  the  same  time  the  diffi- 
culty is  enhanced  by  the  danger  of  benign  growths  becoming  trans- 
formed in  their  character.  Bosworth  reports  a  case  in  which  sar- 
coma developed  after  polypi  had  been  operated  upon  rather  harshly 
by  means  of  forceps,  and  a  similar  case  is  narrated  by  Heyman.^ 
Traumatism  has  been  also  observed  to  result  in  fibrosarcoma  and 
other  malignant  growths  of  the  nasal  chambers. 

The  reflex  disorders  arising  from  naso-pharyngeal  obstruction,  by 
hypertrophies  or  new  growths,  have  been  studied  by  a  multitude  of 
clinical  observers.  Obstinate  headache,  asthenopia,  earache,  persist- 
ent cough,  and  vertigo  are  symptoms  of  special  cases  of  nasal  dis- 
order. Voltolini  first  directed  attention  to  the  fact  that  nasal  polypi 
may  be  the  cause  of  asthma.,  and  a  deflected  septum  and  hypertrophic 
rhinitis  are  also  claimed  as  causes  by  Bosworth.  Weber  showed  that 
diseases  in  the  upper  air-passages  readily  produce  turgescence  and 
swelling  of  the  bronchial  mucous  membrane.  Glycosuria  has  been 
known  to  originate  in  nasal  obstruction,  and  to  disappear  when  this 
was  removed.^  Nasal  polypi  apparently  may  cause  spasmodic  stric- 
ture and  difficulty  in  urinating,  as  in  a  case  reported  by  Mulhall ;  ^  the 
stricture  was  at  once  relieved  by  the  removal  of  the  nasal  polypi. 

Rhinoscleroma  is  a  form  of  new  growth  allied  to  round-celled 
sarcoma,  characterized  by  the  appearance  of  flat,  slightly  raised 
patches  which  are  smooth  on  the  surface  and  of  ivory-like  hard- 
ness, and  which  first  appear  at  the  edges  of  the  nostril,  spread  to 
the  upper  lip,  and  do  not  ulcerate.  Von  Frisch  discovered  in  the 
growths  little  bacilli,  resembling  the  pneumococcus  of  Friedlander, 
and  like  the  latter  encapsulated,  but  differing  from  it  in  its  response 


^  Revue  Mensuelle  de  Laryngologie,  1888,  p.  24. 

^  Bayer,  Revue  de  Laryngologie,  1894,  xv.  19. 

^  American  Laryngological  Association,  1892,  p.  42. 


DISEASES  OF  THE  LARYNX  AND  TBACHEA.  233 

to  staining  by  Gram's  method.  Inoculation  has  failed  thus  far  to  re- 
produce the  disease  in  the  lower  animals.^  The  lesion  may  gradually 
extend  into  the  tissues  of  the  mouth  and  nose  and  to  the  larynx. 
Rhinoscleroma  is  to  be  distinguished  from  syphilis,  epithelial  cancer, 
and  keloid.  It  differs  from  venereal  disease  mainly  by  its  very  chronic 
course,  the  absence  of  softening  or  ulceration,  and  its  absolute  in- 
tractability under  every  kind  of  medication.  From  epithelioma  it 
can  be  discriminated  by  its  smooth,  glistening  surface,  its  hardness, 
the  absence  of  bleeding  or  ulceration,  and  its  persistently  local  char- 
acter. The  history  of  the  case  and  its  general  appearance  distinguish 
it  from  keloid,  which  has  the  puckered,  white,  and  irregular  outline 
of  scar-tissue. 

SECTION   II. 

DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

Of  these  affections  those  of  the  larynx  are  far  the  most  frequent  and 
the  most  readily  recognized.  There  are,  indeed,  symptoms  in  laryn- 
geal diseases  which  at  once  direct  attention  to  the  seat  of  the  malady. 
The  larynx  is  the  organ  of  speech :  hence  changes  in  the  voice  consti- 
tute the  most  striking  manifestations  of  disorder.  These  changes 
vary  m  degree.  The  voice  may  be  merely  hoarse  or  completely  lost. 
In  young  children  the  different  tone  of  the  cry  corresponds  to  the 
altered  voice  of  adults.  The  alteration  of  the  voice  depends  almost 
wholly  upon  an  affection  of  the  vocal  cords,  and  this  may  be  organic, 
such  as  inflammation,  oedema,  ulceration,  cicatrices,  and  morbid 
growths  ;  or  it  may  proceed  from  perverted  or  impaired  innervation. , 
Very  often  the  hoarseness  or  loss  of  voice  is  caused  by  diminished 
tension  and  want  of  certain  and  prompt  action  of  the  vocal  cords, 
whether  connected  with  structural  change  or  not.  The  same  cause 
gives  rise,  for  the  most  part,  to  the  modifications  of  the  voice,  which 
show  themselves  as  huskiness  in  speaking,  or  in  the  loss  of  certain 
notes  in  singing. 

Next  to  the  voice  in  diagnostic  importance  stand  the  character 
of  the  breathing  and  the  cough.  The  breathing  is  labored  and  diffi- 
cult, and  is  frequently  perceived  to  be  noisy,  and  coarse'  or  shrill, — 
the  so-called  laryngeal  stridor:  a  sign  encountered  whenever  the 
orifice  through  which  the  air  has  "to  pass  is  narrowed,  either  tempo- 
rarily by  a  spasm,  or  more  permanently  by  any  state  which  gives  rise 
to  a  constriction  of  the  parts  ;  for  instance,  by  swelling  of  the  mucous 
membrane,  or  diphtheritic  deposit. 

^  Text-Book  upon  the  Pathogenic  Bacteria,  by  Jos.  McFarland,  Philadelphia,  1898. 

15 


234  MEDICAL  DIAGNOSIS. 

The  difficulty  in  breathing  is  in  some  cases  slight ;  in  others  great. 
One  of  the  peculiarities  of  laryngeal  dyspnoea  is  its  tendency  to  recur 
in  paroxysms,  during  which  the  patient  appears  to  be  in  imminent 
danger  of  strangling.  These  fits  of  suffocation  are  produced  mostly 
by  a  spasm  of  the  intrinsic  muscles,  particularly  the  adductors  of  the 
larynx.  Attacks  of  dyspnoea  also  are  met  with  in  cases  of  paralysis 
of  the  abductors  of  the  larynx,  or  paralysis  of  the  posterior  crico- 
arytenoid muscles.  The  attacks  occur  in  pure  spasm  of  the  glottis ; 
in  croup  ;  in  oedema  of  the  larynx  ;  in  ulceration  and  in  polypi  of  the 
larynx. 

The  cough  of  laryngeal  affections  presents  frequently  the  same 
peculiarity  as  the  dyspnoea, — it  happens  in  paroxysms.  Another  pecu- 
liarity, although  not  one  so  constant,  is  its  harsh  and  ringing  tone. 
The  cough  is  often  short  and  dry  ;  sometimes  it  is  followed  by  muco- 
purulent expectoration  of  roundish  shape,  or  by  -a  blood-streaked 
sputum,  or  by  the  spitting  up  of  false  membrane.  It  is  readily  ex- 
cited by  the  act  of  swallowing,  its  seat  is  referred  by  the  patient  him- 
self to  the  windpipe,  and  is  especially  troublesome  at  night. 

Pain  is  not  so  unusual  a  symptom  of  laryngeal  disease  as  either 
cough  or  changed  breathing.  In  chronic  affections  it  may  be,  indeed, 
wanting.  It  is  rarely  severe  ;  often  more  a  sensation  of  tickling,  of 
burning,  or  of  uneasiness  than  of  actual  pain.  It  is  apt  to  extend 
down  the  trachea  to  the  upper  part  of  the  sternum.  Sometimes  it  is 
increased  on  pressure,  as  in  acute  laryngitis  and  in  ulceration  of  the 
mucous  membrane  ;  and  it  may  be  also  augmented  by  the  act  of 
swallowing. 

By  the  symptoms,  then,  of  altered  voice,  cough,  dyspnoea,  and,  in 
some  cases,  of  local  pain  and  difficulty  in  deglutition,  we  recognize  a 
laryngeal  affection.  But  to  do  so  with  accuracy,  the  larynx  must  be 
inspected  with  the  laryngoscope.  It  may  be  either  circular,  square, 
or  oval.  The  circular  mirror  occasions  least  irritation.  The  larger 
the  mirror  we  can  employ,  the  better  is  the  image. 

The  mirror  is  in  some  cases  all  that  is  necessary  to  practise  laryn- 
goscopy. It  is  heated  in  warm  water  or  over  a  lamp  and  then  intro- 
duced into  the  back  of  the  mouth  in  the  manner  presently  to  be 
described ;  the  person  to  be  examined  having  been  placed  with  his 
face  towards  the  sunlight,  so  that  its  rays  may  strike  the  laryngeal 
mirror. 

But  examinations  by  direct  light  are  practicable  only  on  clear  days 
and  at  certain  periods  of  the  day.  Usually  we  require  a  second 
mirror  to  illuminate  the  throat  and  the  laryngoscope.  This  mirror  is 
of  circular  form,  about  three  inches  and  a  half  in  diameter,  and  with 


DISEASES  OF  THE  LARYNX  AND  TRACHEA. 


235 


Fig.  15. 


a  focus  of  about  fourteen  inches. 
It  may  be  either  attached  to  the 
head  by  means  of  a  band,  or  worn 
on  a  pair  of  spectacle-frames,  or 
placed  on  a  movable  stand,  or 
affixed  to  a  lamp.  When  the 
frontal  band  is  made  use  of,  the 
observer  may  either  place  the 
mirror  opposite  to  one  of  his 
eyes,  and  look  through  the  central 
perforation,  or  adopt  the  easier 
method  of  wearing  the  reflector 
on  his  forehead. 

The  light  may  be  concentrated 
directly  into  the  throat  by  a  lens 
or  a  bull's-eye  condenser,  or  by  a  combination 
of  lenses  attached  to  a  metallic  frame  fastened 
to  a  lamp,  as  in  the  well-known  apparatus  of 
Tobold  numerously  modified.  A  good  light  to 
employ  is  coal  oil ;  the  most  convenient,  an 
argand  or  a  Welsbach  gas-burner.  I  have 
used  the  electric  light  very  satisfactorily.  A 
portable  electric  light  is  obtainable  by  the  aid 
of  a  small  storage  battery,  which  can  be  used 
at  the  bedside. 

To  examine  the  larynx  by  artificial  light, 
we  should  proceed  thus.  The  patient,  sitting 
in  an  upright  position,  with  his  head  inclined 
slightly  backward,  is  placed  near  a  lamp,  burn- 
ing with  a  steady,  brilliant  light,  the  flame  of 
which  is  behind  and  about  on  a  level  with  his 
eyes.  He  is  directed  to  open  his  mouth  widely, 
to  put  out  his  tongue",  and  to  hold  between  two 
fingers  its  point  enveloped  in  a  soft  napkin  or 
handkerchief.  If  he  cannot  accomplish  this 
readily,  the  examiner  must  hold  the  protruded 
tongue,  or  a  tongue-depressor  must  be  em- 
ployed. The  observer  now  seats  himself  di- 
rectly in  front  of  the  patient,  and  nearly  a  foot 
from  the  mouth.  Putting  on  his  spectacles  or 
frontal  band,  he.  throws  a  disk  of  light  into  the  i^^ryngoscopes  of  various  shape ; 

1        ,  inn  11        1        n  -Ti.,  not  quite  natural  size. 

back  part  oi  the  mouth  ;  he  then  rapidly  mtro- 


236 


MEDICAL  DIAGNOSIS. 


duces  the  laryngeal  mirror,  previously  heated  in  warm  water  or  over 
a  lamp  and  its  proper  temperature  ascertained  by  touching  his  own 
hand  or  cheek.  The  mirror,  great  care  being  taken  not  to  bring  it  in 
contact  with  the  tongue,  is  placed  with  its  back  against  the  uvula, 
which,  with  the  soft  palate,  is  pressed  backward  and  upward ;  the 
lower  surface  of  the  laryngoscope  should  be  firmly  applied  to,  or,  if 
this  be  found  to  occasion  too  much  irritation,  should  be  held  near, 
the  posterior  wall  of  the  pharynx.  The  inclination  of  the  mirror 
varies  with  the  position  of  the  patient  and  the  parts  we  wish  particu- 
larly to  explore.  As  a  general  rule,  it  may  rest  at  an  angle  of  about 
forty-five  degrees. 

Fig.   16. 


Laryngoscopic  examination,  as  made  with  the  reflector  attached  to  a  spectacle-frame. 

When  one  of  the  ordinary  stationary  laryngoscopic  lamps  is 
employed,  the  reflector  is  attached  to  the  lamp  by  a  freely  movable 
brass  rod,  and  the  light  -concentrated  on  it  is  thus  thrown  into  the 
mouth.  In  the  laryngeal  mirror  the  image  is  readily  perceived.  We 
see  the  epiglottis,  the  glottis,  the  cartilages,  the  true  vocal  cords,  the 
superior  thyro-arytenoid  ligaments  or  ventricular  bands,  and  in  some 
cases  even  the  rings  of  the  trachea.     We  may  be  able  to  discern  each 


DISEASES  OF  THE  LARYNX  AND  TRACHEA. 


237 


Fig.  17. 


Laryngeal  image,  as  seen  in  the  laryngo- 
scope under  favorable  circumstances. 


portion  of  the   laryngeal  aperture  with  distinctness,  or  it  may  take 
several  examinations  to  do  so. 

In  health,  the  color  of  the  various  parts  is  very  different.  Stoerck 
has  well  described  it  in  likening  that  of  the  epiglottis,  the  interior  of 
the  larynx  below  the  glottis,  and  of 
the  cricoid  cartilage,  to  the  coloration 
of  the  conjunctiva  of  the  eyelid  ;  and 
the  hue  of  the  aryepiglottidean  folds 
and  the  prominences  of  the  arytenoid 
cartilages  to  that  of  the  gums.  The 
mucous  membrane  of  the  trachea 
between  the  rings  is  of  a  pale  pink 
color  ;  the  vocal  cords  have  a  white, 
glistening  look.  Mackenzie  takes  spe- 
cial notice  of  the  whole  of  the  under 
surface  of  the  epiglottis  being  in 
some  cases  of  a  bright-red  hue  ;  and 

Gibb  points  out  that  in  negroes  the  cartilages  of  Wrisberg  have  a 
yellowish  tinge. 

The  laryngeal  image  in  the  mirror  bears  this  relation  to  the  real 
position  of  the  parts :  the  right  vocal  cord  of  the  person  who  is  ex- 
amined is  seen  on  the  left  side  of  the  mirror,  and  the  left  vocal  cord 
on  the  right ;  or,  to  state  the  matter  in  a  form  easy  to  be  remembered, 
the  cord  which  corresponds  to  the  right  hand  of  the  patient  is  the 
right,  that  seen  towards  his  left  hand  is  the  left.  The  epiglottis  ap- 
pears in  the  laryngoscope  at  the  upper  portion  and  behind ;  so  do  the 
other  structures  that  lie  in  front.  The  arytenoid  cartilages  show  at  its 
lower  portion,  and  towards  the  front. 

To  judge  of  the  movements  of  the  vocal  cords,  we  tell  the  patient 
alternately  to  inspire  deeply  and  to  utter,  as  a  prolonged  high  note,  a 
sound  like  "  ah."  During  this  the  vocal  cords  are  closely  approxi- 
mated and  stretched,  and  the  epiglottis,  in  fact  the  whole  larynx,  is 
somewhat  elevated ;  while  during  a  full  inspiration  the  cords  are  far 
apart,  and  hence  the  glottis  is  wide  open.  To  obtain  a  satisfactory 
sight  of  the  deeper-seated  parts,  we  must  bear  in  mind  that  the  more 
horizontally  the  surface  of  the  mirror  is  placed,  the  more  distinctly 
they  come  into  view.  For  the  Bxploration  of  these  structures,  and 
particularly  of  the  trachea,  the  light  must  be  thrown  from  below  up- 
ward upon  the  laryngoscope.  To  elevate  the  larynx  decidedly,  and 
especially  to  bring  the  epiglottis  fully  into  view,  the  patient  should  in 
a  high  pitch  pronounce  ee  as  in  the  word  see. 

In  some,  laryngoscopy  is  easy ;  a  conclusive  examination  may  be 


238  MEDICAL   DIAGNOSIS.         ^     ' 

made  at  the  first  attempt.  In  others,  a  course  of  training  is  required 
to  subdue  the  sensibility  of  the  fauces,  which  may  be  general,  or  be 
limited  to  a  very  small  spot.  As  a  means  of  overcoming  the  difficulty, 
sucking  small  pieces  of  ice,  or  the  previous  administration  of  bromide 
of  potassium,  or  the  local  use  of  a  solution  of  cocaine  from  two  to 
five  per  cent.,  is  useful.  But  the  best  means  is  skill  in  the  use  of  the 
instrument, — its  rapid  and  decisive  handling.  The  administration  of 
an  anaesthetic  may  be,  however,  necessary.  This  is  especially  the 
case  in  refractory  children  suffering  with  papilloma  or  other  conditions 
demanding  ocular  inspection.  To  overcome  pharyngeal  and  laryngeal 
reflexes,  Scanes  Spicer^  recommends  the  cautious  use  of  a  ten  per 
cent,  spray  of  solution  of  cocaine,  and,  for  removal  of  salivary  secre- 
tions, the  free  use  of  dry  mops  of  absorbent  cotton-wool. 

In  some  persons  with  very  irritable  throats,  I  have  obtained  good 
views  by  pressing  the  instrument  against  the  roof  of  the  mouth,  in- 
stead of  passing  it  back  into  the  pharynx,  and  by  altering  the  position 
of  the  head  a  little,  tilting  it  more  backward.  The  epiglottis,  and  the 
structures  at  the  entrance  of  the  windpipe,  are  thus  readily  enough 
brought  into  view  :  with  the  deeper  parts  we  do  not  succeed  so  well ; 
but  in  many  cases  we  get  sufficient  guide  for  topical  applications. 
There  are  further  obstacles,  such  as  a  rising  up  of  the  tongue,  greatly 
enlarged  tonsils,  a  long  uvula,  a  pendent  epiglottis,  all  of  which  at 
times  interfere  with  our  investigations.  But  in  any  case  we  should 
not  endeavor  to  make  the  view  more  satisfactory  by  constantly  alter- 
ing the  position  of  the  mirror.  It  is  better  to  introduce  it  repeatedly 
than  to  shift  it  often  when  introduced,  or  to  keep  it  for  any  length  of 
time  in  the  patient's  mouth.  Digital  examination  of  the  larynx  with 
the  index-fmger  is  an  expedient  of  value  in  children  and  others  who 
will  not  iDermit  laryngoscopy.  It  is  practised  for  diagnostic  purposes 
in  laryngeal  oedema,  and  in  new  growths,  such  as  papilloma. 

Direct  examination  of  the  larynx  can  be  made  in  a  certain  propor- 
tion of  cases  by  Kirstein's  instrument,  which  is  a  modified  tongue- 
depressor  connected  with  an  electroscope.  The  epiglottis  and  pharynx 
having  been  painted  with  cocaine,  or  the  patient  moderately  an^es- 
thetized,  the  instrument  is  introduced  into  the  mouth  so  that  by  its 
aid  the  base  of  the  tongue  may  be  pulled  strongly  forward,  and  the 
larynx  be  brought  directly  in  line  with  the  eye  of  the  physician.  This 
method  is  also  useful  to  aid  in  the  removal  of  new  growths  or  foreign 
bodies.  Waggett  has  shown  how  the  X-rays  may  be  utilized  to  locate 
foreign  bodies  in  the  larynx  and  oesophagus,  and  to  determine  the 

^  Journal  of  Laryngology,  Rhinology,  and  Otology,  London,  Oct.  1894. 


DISEASES  OF  THE  LAHYNX  AND  TRACHEA.  239 

relative  position  of  a  probe  and  the  foreign  body.     Some  new  growths 
may  also  be  detected  in  this  manner/ 

If  the  mirror  be  passed  behind  the  uvula,  and  the  reflecting  sur- 
face directed  upward,  the  posterior  nares  may  be  examined.  To 
practise  rhinoscopy^  however,  the  mirror  should  be  small  and  fixed  to 
the  shaft  at  a  right  angle.  The  patient  is  directed  to  keep  his  head 
erect,  or  bend  it  slightly  forward,  and  while  his  mouth. is  wide  open  a 
strong  hght  is  thrown  to  the  back  of  the  throat.  But  before  the 
rhinal  mirror  is  placed  in  position,  a  tongue-depressor  is  applied,  with 
which  the  back  of  the  tongue  is  well  pressed  down,  and  which  may 
be  given  to  the  patient  to  hold.  To  get  the  uvula  out  of  the  way,  a 
palate-hook  may  be  used,  by  which  means  the  uvula,  with  a  portion 
of  the  soft  palate,  is  gently  drawn  forward  and  upward,  the  handle  of 
the  hook  being  held  to  one  side  of  the  mouth :  Voltolini's  palate-hook 
widens  the  pharyngo-nasal  space  satisfactorily,  or  Sajous's  soft  palate- 
elevator  may  be  employed.  But  by  instructing  the  patient  to  breathe 
through  the  nose  and  to  breathe  heavily  while  the  mouth  is  open,  we 
obtain  relaxation  of  the  muscles  of  the  soft  palate,  and  in  most  cases, 
after  a  little  training,  may  dispense,  for  diagnostic  purpose,  with  the 
palate-retractor.  The  mirror,  with  its  reflecting  surface  upward,  is 
now  passed  along  the  tongue-depressor,  until  it  reaches  the  posterior 
wall  of  the  pharynx.  By  then  raising  somewhat  the  handle  of  the 
mirror,  we  obtain  a  view  of  the  vomer ;  and  by  slanting  the  mirror 
first  towards  one  side  and  then  towards  the  other,  the  posterior  nares 
and  the  orifices  of  the  Eustachian  tubes  may  be  inspected,  and  the 
vault  and  posterior  wall  of  the  naso-pharynx. 

The  chief  diseases  of  the  larynx,  grouped  in  accordance  with  their 
main  features,  may  be  arranged  as  follows : 

Acute  Organic  Diseases. 

Congestion,  or  hyperajmia. 

Inflammation  of  the  mucous  membrane  of  the  larynx — Acute  laryngitis. 

(Edema  of  the  larynx. 

Acute  affections  of  the  larynx  ^  r^  i      ■>    ^         ^            j             u                i           ■<• 

•'  batarrhal    and    pseudo-membranous    laryngitis — 

and  trachea  as  met  with  V  r^  ^          i  i 

[  liaise  and  true  croup, 
m  children.                         j 

Specific  affections — Syphilis,    tuberculosis,    lepra,    diphtheria,    erysipelas,    typhoid, 

etc. 

Chronic  Organic  Diseases. 

Inflammation  of  the  mucous  membrane  of  a  part,  or  of  the  whole — Chronic  laryn- 
gitis in  its  various  forms — Abscess. 
Destruction  of  the  cartilages. 

^  Journal  of  Laryngology,  1896  ;  Gould's  Year-Book,  1897,  p.  1020. 


240  MEDICAIi  DIAGNOSIS. 

Growths  and  tumors  of  various  kinds. 
Ulcers,  simple  and  specific. 

Muscular  degenerations,  occurring  after  acute  infectious  disease  (such  as  typhoid 
fever). 

Affections  of  the  Nerves. 

Spasm  of  the  larynx.      (Spasmodic  croup  and  laryngismus  stridulus.) 

1  Functional,    or  purely  nervous   aphonia.      (Hysterical,    or  due 
to  debility.) 
Organic,  due  to  paralysis  of  the  muscles  of  the  vocal  cords. 
Chorea  of  the  larynx. 

Acute  Laryngeal  Affections. 

Acute  Laryngitis. — In  its  mild  form,  acute  laryngitis  is  neither 
an  micommon  nor  a  dangerous  disease.  In  its  severe  form  it  is  much 
more  uncommon,  and  very  much  more  dangerous.  When  it  is  slight, 
it  occasions  simply  hoarseness  ;  a  feeling  of  tickling  and  irritation  in 
or  near  the  larynx ;  a  trifling,  though  annoying,  cough,  or  rather  a 
constant  disposition  to  clear  the  throat,  more  than  a  cough ;  and, 
owing  in  a  great  measure  to  a  co-existing  inflammation  of  the  fauces, 
some  difficulty  in  swallowing.  The  disorder  passes  off  in  the  course 
of  a  few  days. 

When  the  inflammation  is  violent,  and  especially  when  it  involves 
the  submucous  tissues,  the  symptoms  are  much  aggravated.  The 
respiration  becomes  seriously  impeded ;  with  each  breath  a  wheezing 
or  whistling  noise  is  heard.  There  is  but  little  expectoration,  and  the 
cough  is  distressing  and  painful,  and  has  a  harsh  sound.  The  voice 
is  hoarse,  or  sinks  into  a  scarcely  audible  w^hisper ;  the  windpipe  is 
tender  when  pressed.  There  is  in  the  throat  a  feeling  of  constriction, 
difficulty  in  swallowing,  and  fever,  with  a  full  pulse  and  flushed  face. 
If  the  case  advance  unchecked,  the  countenance  becomes  distressed 
and  pale,  the  lips  bluish,  the  pulse  irregular,  and  death  sets  in  with 
all  the  signs  of  deficient  aeration  of  the  blood  and  of  strangulation. 

The  disease  in  its  graver  form  runs  a  very  rapid  course.  If  in  a 
few  days  after  its  beginning  no  improvement  show  itself,  life  does  not 
last  long.  Sometimes  death  takes  place  on  the  first  day  of  the  attack  ; 
it  rarely  waits  for  the  sixth.  (Edema  of  the  laryngeal  mucous  mem- 
brane is  often  the  consequence  of  the  inflammation  and  the  cause  of 
the  danger. 

The  marked  symptoms  of  the  perilous  complaint  prevent  it  from 
being  overlooked,  and  render  its  discrimination  easy.  There  is  fever 
with  dyspnoea  in  the  aaute  pulmonary  affections  ;  but  the  voice  remains 
unaltered,  and  they  exhibit  physical  signs  which  acute  laryngitis  does 
not, — they   show   rales,    or   abnormal   respiration-sounds ;    while  in 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  241 

laryngitis  the  murmur  of  the  lungs  is  that  of  health,  although  it  is 
sometimes  enfeebled  by  the  impediment  in  breathing,  or  obscured  by 
the  shrill  sound  which  issues  from  the  larynx.  We  find  difficulty  in 
swallowing  and  some  hinderance  in  breathing  in  tonsillitis;  but  in- 
spection of  the  oral  cavity  immediately  detects  the  source  of  the  dis- 
order. There  is  difficulty  in  swallowing  in  pharyngitis,  but  there  is 
not  embarrassed  breathing,  or  a  peculiar  voice,  or  cough,  and  the 
fauces  appear  dusky  and  injected,  while  they  are  but  slightly  affected 
in  laryngitis,  unless  inflammation  of  the  larynx  have  supervened  upon 
that  of  the  throat. 

An  affection  of  the  larynx  occurring  only  in  winter,  laryngitis  hie- 
malis,  has  been  described  by  Mulhall,  in  which  the  secretions  form  ad- 
hesive crusts,  producing  difficulty  in  speaking,  or  more  often  aphonia. 
This  is  to  be  diagnosticated  from  laryngitis  sicca,  which  is  a  part  of  a 
general  process,  and  follows  pharyngitis  sicca  and  atrophic  rhinitis. 

There  is  a  peculiar  form  of  inflammation  of  the  larynx,  diffuse 
cellular  laryngitis,  a  diffuse  inflammation  of  the  cellular  tissue,  with 
lymph  or  pus  infiltrated  in  the  submucous  tissue,  to  which  attention 
has  been  called  by  Henry  Gray.^  It  is  a  formidable  affection,  which 
bears  a  strong  likeness  to  erysipelatous  laryngitis,  but,  what  is  not  by 
any  means  constantly  the  case  in  this  disorder,  the  symptoms  begin 
in  the  fauces  and  larynx ;  and,  wholly  unlike  erysipelatous  laryngitis, 
the  submucous  tissue  is  primarily  attacked,  and  the  neck  becomes 
greatly  swollen  from  the  effused  products  ai-ound  the  larynx,  trachea, 
and  oesophagus  filling  its  cellular  tissue.  The  disease  begins  with 
chills,  soreness  of  throat,  and  fever,  soon  succeeded  by  dyspnoea,  by 
a  dusky  hue  of  the  fauces,  by  enlargement  of  the  tonsils  and  of  the 
glands  in  the  neighborhood  of  the  jaw,  and  by  great  difficulty  in 
swallowing.  The  neck  increases  greatly  in  size,  the  fever  assumes  a 
low  type,  and  the  patient  either  sinks  gradually  or  dies  asphyxiated, 
perishing  sometimes  rapidly  from  a  speedy  increase  of  the  laryngeal 
tumefaction. 

Other  forms  of  inflammation  of  the  larynx  to  which  attention  has 
of  late  years  been  called  are  hemorrhagic  laryngitis,  an  acute  catarrh 
of  the  larynx,  attended  by  bleeding  from  the  inflamed  membrane, 
and  laryngeal  rheumatism.  This  generally  happens  in  persons  of 
rheumatic  diathesis,  is  attended  with  considerable  pain,  and  may  or 
may  not  be  associated  with  other  signs  of  rheumatism.^  There  are 
eases  in  which  laryngeal  symptoms  are  marked,  and  cases  without 


^  Holmes's  System  of  Surgery,  vol.  iv. 
2  Archambault,  These  de  Paris,  1886. 


242  MEDICAL  DIAGNOSIS. 

them.  Roos  reports  ^  several  instances  of  rheumatic  angina  that  ter- 
minated in  attacks  of  general  rhemnatic  arthritis.  The  principal 
features  of  rheumatic  angina  are  excessively  painful  deglutition,  red- 
ness and  swelling  of  one  or  both  tonsils ;  the  disease  is  of  slow  de- 
velopment, and  occurs  usually  ^vithout  abscess-formation.  It  has 
been  suggested  that  the  joint  affections  are  really  secondary'  manifes- 
tations, pseudo-rheumatic  in  character,  and  that  the  polyarthritis 
belongs  to  the  category  of  attenuated  pyaemic  infections.  H.  L.  Wag- 
ner has  found  articular  rheumatic  affections  followmg  follicular  amyg- 
dalitis, in  which  bacterial  investigation  showed  that  the  syno^dal  fluid 
obtained  by  tappmg  the  joint  contained  the  same  micro-organisms  as 
were  found  in  the  diseased  tonsil.^ 

Following  inflammation  or  ulceration  of  the  larynx,  various  irregu- 
larities may  occur  as  the  result  of  cicatricial  contraction,  or  adhesions 
between  the  cords,  wliich  may  be  studied  ^^dth  the  aid  of  the  laryngo- 
scope. There  are  usually  alterations  in  the  voice,  with  attacks  of 
dyspncea  simulatmg  asthma,  and  impairment  of  general  nutrition. 

(Edema  of  the  Larynx. — The  danger  in  acute  lar^mgitis  of  any 
kuid  is  much  aggravated  by  the  jDrecise  seat  of  the  disease.  When 
the  inflammation  takes  place  immediately  around  the  glottis,  and 
causes  a  serous  fluid  to  transude,  cedematoiis  laryngitis,  the  peril  is 
greatly  mcreased.  The  inspiration  is  audible,  noisy,  hissmg,  and 
labored ;  there  is  a  distressing  sensation  of  constriction  or  obstruction 
in  the  wmdpipe,  and  the  patient  makes  repeated  efforts,  by  swallow- 
ing or  by  hawking,  to  clear  'his  throat  of  the  substance  which  seems 
to  be  clogging  it.  His  difficulty  of  breatliuig  is  intense,  and  occurs  in 
frightful  paroxysms,  sometimes  of  a  quarter  of  an  hour's  duration,  in 
wliich  strangulation  appears  to  be  imminent ;  and,  indeed,  often  these 
patients  do  perish  by  strangulation. 

Tills  grave  disease,  oedema  of  the  larynx,  sometmies  follows  an  ex- 
tension of  the  peculiar  inflammation  of  the  throat  in  the  exanthemata, 
or  is  of  erysipelatous  origin,  and  it  occasions  death  quickly,  and  amid 
great  suffering.  But  the  oedema  may  arise  without  preceding  acute 
inflammation,  whether  this  be  specific  or  not.  It  may  result  from 
long-continued  pressure  on  the  trachea  or  larjmx,  or,  in  exceptional 
instances,  occur  in  connection  with  Bright's  chsease.  Again,  an  effu- 
sion of  serum  may  cause  death  suddenly  in  a  person  who  has  been 
laboring  under  a  chronic  laryngeal  disorder.     Such  cases  of  oedema 

^  Revue  de  Laryngologie,  etc.,  1895. 

^  Rheumatic  Affections  of  the  Body  due  to  Tonsillar  Disease,  Trans.  Amer. 
Larj'ngol.  Assoc,  1894. 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  243 

of  the  larynx  are  distinguished  from  those  of  active  laryngeal  inflam- 
mation by  the  absence  of  fever,  of  local  tenderness,  and  of  marked 
difficulty  of  deglutition.  It  is  true  that,  if  the  oedematous  affection 
ensue  upon  a  chronic  inflammation  of  the  larynx,  tenderness  and  an 
impediment  in  swallowing  may  be  observed.  But  the  history  of  the 
malady  and  the  non-existence  of  fever  leave  little  room  for  error. 

The  diagnostic  sign  proposed  for  oedema  of  the  larynx — the  swell- 
ing of  the  epiglottis,  as  ascertained  by  the  touch — cannot  be  relied 
upon,  because  this  swellmg  does  not  always  exist  to  an  obvious  de- 
gree, and  even  when  it  does  exist,  is  not  readily  determined  by  the 
finger.  In  the  acute  cases  of  cedematous  laryngitis  the  laryngoscope 
shows  a  bright-red  mucous  membrane  ;  sometimes  the  tumid  epiglot- 
tis presents  the  appearance  of  two  round  red  swellings.  It  is  gener- 
ally erect,  tense,  and  turban-shaped.  The  cedema,  in  rare  instances, 
may  be  altogether  below  the  glottis. 

Croup. — Croup  is  inflammation  of  the  larynx  and  trachea ;  but  it 
is  something  more.  It  is  a  spasmodic  action  of  the  muscles  of  the 
larynx,  which  spasmodic  action  gives  rise  to  much  of  the  peculiar 
cough,  the  stridor,  and  the  paroxysms  of  dyspnoea,  so  characteristic 
of  the  disease.  As  croup  is  thus  an  affection  composed,  as  it  were, 
of  several  distinct  elements,  it  differs  somewhat  according  as  one  or 
the  other  of  these  elements  preponderates.  Thus,  the  inflammation 
may  be  comparatively  slight,  yet  the  spasm  plays  a  very  prominent 
part ;  or  the  inflammation  may  be  very  severe,  and  result  in  the  for- 
mation of  a  false  membrane.  To  the  first  class  belongs  the  disorder 
known  as  false  croup,  catarrhal  croup,  spasmodic  croup,  spasmodic 
laryngitis  ;  to  the  second,  the  true  or  membranous  croup. 

False  or  Catarrhal  Croup. — This  is  one  of  the  most  common  dis- 
eases of  childhood.  Its  seizures  happen  chiefly  at  night ;  and  the  child 
that  has  gone  to  bed  well,  or  perhaps  fretful  from  teething,  or  with 
indigestion  after  a  hearty  supper,  or  with  a  slight  catarrh,  wakes  up 
suddenly  in  a  state  of  alarm,  breathing  with  difficulty.  It  coughs  with 
violence  at.  short  intervals,  and  the  cough  is  loud  and  ringing  and 
hoarse ;  and  so  are  the  voice  and  the  cry.  Each  inspiration  is  at- 
tended with  that  shrill,  "  croupy"  sound  which,  once  heard,  is  never 
forgotten.  The  face  is  flushed,  the  pulse  frequent,  the  temperature 
but  little  above  the  normal.  The  paroxysm  continues  in  this  man- 
ner for  about  an  hour :  the  breathing  then  becomes  quiet,  the  child 
falls  asleep,  and  rests  well  until  towards  morning,  when  the  attack  is 
apt  to  be  renewed.  The  little  patient  may,  however,  escape  this  alto- 
gether, and  keep  well ;  or  else  the  paroxysm  recurs  the  next  night,  or 
for  several  nights  in  succession.     In  the  intervals  the  voice  and  respi- 


244  MEDICAL  DIAGNOSIS. 

ration  are  natural,  there  is  little  or  no  fever,  little  or  no  cough.  Yet 
sometimes  a  cough  occurs,  during  the  day,  which  has  every  now 
and  then  a  croupal  sound ;  the  voice,  too,  is  slightly  hoarse. 

Catarrhal,  or  false,  croup  most  frequently  follows  exposure.  It  is 
very  rarely  fatal.  The  laryngoscope  shows  marked  congestion  with 
swelling  of  the  mucous  membrane  and  copious  muco-purulent  secre- 
tion. Cases  in  which  the  inflammation  is  extensive  and  severe,  with- 
out having  led  to  a  plastic  exudation,  and  in  which  the  inflammation 
is  apt  to  be  chiefly  subglottic,  approach  in  their  persistency  and  in  the 
character  of  their  symptoms  very  closely  to  true  croup.  Indeed,  one 
form  of  the  complaint  may  run  into  the  other,  warranting  the  assump- 
tion that  they  are  not  two  diseases,  but  only  two  forms  of  the  same 
disease.  Spasmodic  croup  may  be  a  symptom  of  abnormalities,  such 
as  of  hypertrophies  or  of  adenoid  growths  in  the  nose  or  pharynx, 
and,  if  persistent,  should  suggest  a  digital  or  rhinoscopic  examination. 

The  main  element  in  the  production  of  the  symptoms  of  false 
croup  is  undoubtedly  spasm  of  the  glottis.  But  laryngismus  stridulus, 
as  laryngeal  spasm  or  spasm  of  the  glottis  is  called  by  many,  is  a  neu- 
rosis which,  while  it  may  complicate  any  affection  of  the  larynx  and 
trachea,  may  also  exist  independently,  from  central,  or  direct,  or 
reflex,  causes  of  irritation.  The  laryngeal  spasm  may,  therefore,  form 
a  distinct  disorder,  which  differs  from  catarrhal  croup  by  the  absence 
of  all  inflammation  and  by  several  circumstances  which  proclaim  its 
non-identity,  such  as  its  usual  connection  with  rickets,  and  its  fre- 
quent association  with  other  convulsive  symptoms, — with  distortion 
of  the  face,  rolling  up  of  the  eyes,  spasmodic  contraction  of  the  hands 
and  feet,  and  general  convulsions.  Laryngismus  and  tetany  are  often 
associated  ;  indeed,  by  many  laryngismus  is  looked  upon  as  the  laryn- 
geal expression  of  tetany.  The  Trousseau  sign  of  tetany — pressure 
upon  the  large  arteries  and  nerves  of  a  limb  developing  a  paroxysm 
of  tetany — is  said  to  be  never  absent  in  the  laryngo-spasm.^ 

Some  cases  of  supposed  purely  nervous  laryngeal  spasm  in  chil- 
dren are  undoubtedly  symptomatic  of  laryngeal  growths,  or  of  paral- 
ysis of  intrinsic  muscles,  and  are  really  attacks  of  dyspnoea  due  to 
laryngeal  obstruction.  Laryngoscopic  examination  should  be  made 
in  severe  cases,  even  though  an  ansesthetic  be  required.  Laryngis- 
mus stridulus  is  an  affection  of  children  under  two  years  of  age. 
Crying  may  bring  on  the  attacks,  the  child  dying  of  suffocation  or 
during  convulsions.  In  some  cases  mentioned  by  Mackenzie,  the 
attack  assumes  the  form  of  a  sudden,  almost  soundless,  spasm  that 

^  Escherich,  Address  before  the  Tenth  International  Congress. 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  245 

does  not  relax  until  life  is  extinct.  Spasm  of  the  glottis  in  infants 
may  be  caused  by  an  enlarged  uvula,  as  in  cases  reported  by  Hugel :  ^ 
and  Eustace  Smith  ^  cites  a  case  of  laryngeal  stridor  in  a  three  months 
old  infant,  continuing  since  birth,  in  which  adenoids  were  discovered 
in  the  naso-pharynx  and  removed  by  curetting,  with  complete  relief. 

In  laryngismus,  as  in  croup,  the  seizures  are  apt  to  take  place  at 
night.  Generally  the  child  has  been  fretful  from  teething,  or  from 
gastric  or  intestinal  irritation,  when  suddenly  an  attack  of  difficult 
breathing  occurs,  accompanied  by  several  loud,  crowing  inspirations, 
and  by  threatening  suffocation ;  yet  the  paroxysm  is  not  associated 
either  with  cough,  or  fever,  or  altered  voice,  or  a  materially  changed 
cry.  A  fit  of  this  kind  may  be  repeated  twenty  or  thirty  times  a 
day.  It  may  terminate  fatally  in  a  short  time  ;  usually,  however,  the 
paroxysms  are  spread  over  weeks,  or  even  over  a  longer  period. 

In  addition  to  the  frequent  combination  with  other  convulsive 
symptoms,  the  protracted  duration  of  the  disease,  and  the  absence  of 
febrile  disturbance,  of  hoarseness,  and  of  cough,  point  out  the  distinc- 
tion between  laryngeal  spasm  and  catarrhal  or  spasmodic  laryngitis. 
From  bilateral  palsy  of  the  abductors  of  the  glottis,  laryngismus  is 
readily  distinguished  by  the  great  and  persistent  difficulty  of  breathing 
in  this  affection,  which  is  a  disease  of  adult  life.  Laryngeal  spasm 
also  occurs  in  the  laryngeal  crises  of  tabes  ;  the  absent  knee-jerk  and 
the  ataxia  tell  us  its  meaning. 

In  the  adult,  glottic  spasm  produces  symptoms  to  which  the  name 
of  laryngeal  vertigo  has  been  given ;  the  attack  comes  on  suddenly, 
the  patient  gasps  for  breath  and  becomes  unconscious  and  asphyxi- 
ated.    In  such  cases  there  is  often  attendant  disease  of  the  pharynx. 

True  or  Membranous  Croup. — True  croup  is  a  formidable  affection, 
in  which  there  is  inflammation  that  results  in  the  formation  of  a  false 
membrane.  The  plastic  exudation  is  found  lining  the  larynx,  extend- 
ing at  times  into  the  trachea  or  down  into  the  bronchial  tubes.  With 
rare  exceptions,  cases  of  membranous'  croup  are  the  result  of  infec- 
tion by  the  Klebs-Loeffler  bacillus,  and  are,  therefore,  to  be  regarded 
as  laryngeal  diphtheria.  We  shall  farther  on  examine  into  this  formi- 
dable affection,  and  determine  in  how  far  the  non-diphtheritic  cases 
can  be  distinguished.  Let  us  here  speak  of  the  manifestations  of 
ordinary  membranous  croup. 

In  the  early  stages  of  membranous  croup  we  have  the  same  stridu- 
lous  breathing  and  brazen  cough  as  in  catarrhal  croup.      Gradually 

^  Miinchener  Medicinische  Wochenschrift,  1898,  No.  44. 
*  Lancet,  March  19,  1898. 


246  MEDICAL  DIAGNOSIS. 

the  voice  alters  and  becomes  suppressed,  and  the  signs  of  laryngeal 
obstruction  become  more  evident,  and  shreds  of  membrane  are 
expectorated. 

The  application  of  a  stethoscope  to  the  larynx  or  trachea  does  not 
give  us  much  information  as  to  the  exact  seat  and  the  extent  of  the 
affection  of  the  windpipe.  Still  it  is  not  without  value.  It  may  enable 
us  to  judge  of  the  position  of  the  exudation,  for  we  may  occasionally 
hear  a  vibrating  sound,  as  if  a  membrane  were  being  tossed  to  and 
fro  by  a  current  of  air.  In  a  case  that  came  under  my  notice  some 
years  ago,  this  sign  was  perceived  with  great  distinctness  at  the  lower 
part  of  the  trachea  and  towards  the  commencement  of  the  left  bron- 
chial tulDe  ;  and,  at  the  autopsy,  at  precisely  this  point  was  found  a 
thick  layer  of  membrane  lying  unattached  in  the  tube.  Auscultation 
of  the  lungs,  by  showing  to  what  extent  the  air  is  still  capable  of  en- 
tering them,  furnishes  us  with  a  clue  to  the  degree  of  the  laryngeal 
obstruction. 

Membranous  croup  is  a  disease  not  apt  to  be  mistaken.  When  we 
take  the  symptoms  collectively, — the  ringing  cough,  the  peculiar  res- 
piration, the  dyspnoea  aggravated  in  paroxysms,  the  changed  voice, 
the  fever,  the  expectoration  of  shreds  of  membrane  ;  when  we  regard 
the  comparatively  short  duration  of  the  disease, — there  is,  with  the 
exception  of  the  ever-present  question  of  diphtheritic  origin,  generally 
but  one  interpretation  of  the  phenomena  possible. 

It  is,  of  course,  of  the  utmost  consequence  to  distinguish  between 
spasmodic  laryngitis  or  false  croup  and  membranous  croup.  The 
symptoms  of  the  latter  are  far  graver  and  more  continuous,  the  fever 
is  decided.  But  there  is  only  one  proof  positive, — finding  the  mem- 
brane in  what  is  coughed  up  or  vomited  up,  or  by  a  laryngoscopic 
examination. 

The  disorders,  excluding  diphtheria,  which,  next  to  false  croup, 
are  most  likely  to  be  mistaken  for  membranous  croup,  are :  acute 
laryngitis,  cedema  of  the  larynx,  retropharyngeal  and  retrolaryngeal 
abscesses. 

Acute  laryngitis  in  its  ordinary  form,  such  as  we  see  in  adults,  is  a 
very  rare  disease  in  children.  Acute  catarrhal  laryngitis  is  in  them 
closely  connected  with  the  phenomena  of  spasmodic  croup ;  and  the 
croupy  symptoms,  the  changed  voice,  the  barking  cough,  the  paroxys- 
mal dyspncBa,  the  slight  or  absent  difficulty  in  swallowing,  tell  us  what 
we  are  dealing  with.  In  membranous  croup  these  signs  also  are  in- 
tensified, and  we  are  apt  to  have  high  fever.  A  form  of  laryngitis, 
however,  happens  in  children,  which  is  very  liable  to  be  considered  as 
croup :  it  is  the  secondary  laryngitis  of  the  exanthemata^  especially  of 


DISEASES  OF  THE   LARYNX  AND  TRACHEA.  247 

variola  and  scarlatina.  Attention  to  the  history  of  the  case,  and  to 
the  circumstance  of  the  inflammation  having  spread  from  the  throat 
downward,  will  aid  us  greatly  in  forming  a  correct  opinion  of  the 
disease.  Yet  the  diagnosis  is  sometimes  one  of  extreme  difficulty, 
and  examination  by  the  microscope  and  culture  tests  will  be  needed 
to  determine  whether  or  not  it  is  diphtheritic. 

(Edema  of  the-  larynx  resembles  croup,  in  its  severe  or  its  mem- 
branous form,  in  the  dyspnoea,  the  fits  of  suffocation  and  of  coughing, 
the  altered  voice,  and  the  noisy  inspiration.  It  resembles  it  further  in 
the  fact  that  most  of  the  symptoms  do  not  disappear  in  the  intervals 
between  the  paroxysms.  Here  is  certainly  a  strong  likeness.  But  the 
cough  has  not  the  croupal,  brazen  sound  ;  expiration  is  comparatively 
unembarrassed ;  there  is  no  fever,  unless  the  oedema  occur  in  the 
course  of  an  acute  affection ;  and,  above  all,  cedema  of  the  glottis  is  a 
disease  of  adults.  Again,  the  history  of  the  case  often  guards  against 
error,  for  oedema  of  the  larynx  happens  frequently,  perhaps  most  fre- 
quently, in  those  who  have  been  long  laboring  under  chronic  or  ulcer- 
ative laryngitis ;  it  is  also  seen  among  the  toxic  efi"ects  of  iodide  of 
potassium.  In  cases  in  which  we  are  able  to  use  the  laryngeal  mirror, 
the  peculiar  oedematous  look  of  the  parts  is  readily  recognized. 

Retrojjharpigeal  abscesses  share  with  croup  the  symptoms  of  dysp- 
noea, stridulous  respiration,  and  altered  voice.  They  do  not  share 
with  it  the  peculiar  cough ;  and,  further,  in  croup  there  is  not  the 
difficulty  in  swallowing,  or  the  evident  tumefaction  and  stiffness  of  the 
neck,  nor  can  a  tumor  be  recognized  by  the  touch,  as  it  can  be  when 
an  abscess  is  seated  behind  the  walls  of  the  pharynx.  Moreover,  the 
dyspnoea  and  the  voice  present  somewhat  different  characteristics. . 
In  the  case  of  abscess,  the  former  is  greatly  augmented,  or  paroxysms 
of  it  are  brought  on,  by  attempts  at  deglutition  ;  it  is  always  preceded 
by  dysphagia,  is  increased  by  pressure  against  the  larynx,  and  is 
aggravated  by  the  horizontal  position.  In  croup,  the  patient  seeks 
relief  by  throwing  his  head  back,  and,  although  he  loses  his  voice 
and  speaks  in  a  hardly  audible  whisper,  still  the  words  are  sufficiently 
distinct ;  while  an  abscess  gives  a  nasal  or  gluttural  tone  to  the  voice, 
that  often  makes  it  impossible  to  understand  what  is  being  said. 

Retrolaryngeal  abscesses  following  inflammation  of  the  areolar 
tissue  of  the  retrolaryngeal  space-  present  dyspnoea,  attacks  of  suffo- 
cation, and  cough  like  those  of  croup,  and  run,  moreover,  generally 
an  acute  course;  but  they  also  present  dysphagia  and  severe  pain, 
occasioned  by  pressing  on  the  thyroid  cartilage.^ 

^  Goix.  Archives  Generales  de  Medeciiie,  Ocf.  1882. 


248  •  MEDICAL  DIAGNOSIS. 

Abscess  of  the  larynx  bears  a  strong  resemblance  to  retropharyngeal 
abscess,  and  may  be,  like  it,  mistaken  for  croup.  Abscess  of  the 
larynx  in  its  acute  and  primary  form  is  not  a  frequent  disease ;  rare 
in  adults,  it  is  still  rarer  in  children.  No  swelling  can  be  detected  in 
the  pharynx  to  account  for  the  pain,  the  cough,  the  difficult  breathing 
and  impeded  swallowing ;  but  on  close  observation  it  is  found  that  the 
larynx  projects,  and  that  there  is  induration  at  the  posterior  margin 
of  the  thyroid  cartilage.  The  neck  is  not  markedly  swollen,  as  in 
diffuse  inflammation  of  the  areolar  tissue.  With  the  laryngoscope, 
we  observe  a  circumscribed  swelling,  red  at  its  base,  and  often  yellow- 
ish at  its  apex.  We  do  not  find,  as  we  so  commonly  observe  in  croup, 
that  both  inspiration  and  expiration  are  interfered  with ;  the  latter, 
indeed,  may  be  both  unembarrassed  and  noiseless. 

Abscess  of  the  larynx  may  have  unsuspected  causes.  Poli^  re- 
ported a  case  in  the  discharge  from  which  the  sulphur-yellow  granu- 
lations of  actinomycosis  were  detected.  Watson  Williams  ^  found  the 
Gaffky  typhoid  bacillus  at  the  base  of  ulcers  and  in  the  structures  of 
the  larynx. 

Further,  croup  may  be  mistaken  for  tonsilitis,  for  capillary  bron- 
chitis, for  whooping-cough,  or  for  the  presence  of  foreign  bodies  in 
the  larynx  or  trachea.  But  the  points  of  distinction  are  evident.  In 
tonsillitis,  or  in  tonsillar  abscesses,  the  breathing  is  not  at  all,  or  but 
very  slightly,  impaired ;  and  a  glance  into  the  mouth  is  sufficient  to 
reveal  the  real  nature  of  the  malady.  So  it  is  in  peritonsillar  abscess, 
where  otherwise  the  suffocative  attacks  that  are  prone  to  happen 
might  be  misleading.  In  cajnllary  bronchitis  there  is  dyspnoea,  as  in 
croup ;  but  the  dyspnoea  is  unremitting,  and  associated  with  fme 
rales  in  the  lungs,  and  not  with  a  ringing  cough,  a  harsh  tracheal 
breathing,  a  hoarse  voice.  In  whooping-cough,  paroxysms  of  coughing 
and  of  obstructed  respiration  occur ;  but  then  follows  the  distinctive 
whoop  ;  and  there  is  no  fever,  the  voice  is  not  husky,  and  the  child 
does  not  suffer  between  the  spells.  Foreign  bodies  in  the  windjnpe 
give  rise  to  stridulous  breathing  and  to  cough,  but  they  do  not  often 
mimic  croup  closely  enough  to  deceive ;  and  the  absence  of  the  pecu- 
liar cough  and  of  fever,  and  the  history  of  the  case,  prevent  error; 
so  also  does  attention  to  the  fact  that  the  signs  vary  as  the  foreign 
body  shifts  its  position.  Furthermore,  as  Gross  ^  points  out,  the  em- 
barrassed breathing  caused  by  a  foreign  boidy  is  chiefly  found  in 
expiration. 

1  Gazzetta  degli  Ospitali,  Naples,  May  14,  1894. 
^  Journal  of  Laryngology  and  Otology,  Oct.  1894. 
^  On  Foreisn  Bodies  in  the  Air-Passages. 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  249 

The  diagnosis  of  membranous  croup  has  been  considered  connect- 
edly, because  it  is  convenient  and  practically  useful  to  so  consider  it, 
and  because  I  am  still  of  the  belief  that  there  is  such  a  disease  as 
a  membranous  laryngitis  which  is  not  diphtheria,  though  it  is  rare. 
The  strong  points  in  the  diagnosis  of  non-diphtheritic  membranous 
croup  are :  the  gradual  origin  and  the  slow  deepening  of  the  symp- 
toms ;  the  fact  that  no  membranes  appear  in  other  localities  ;  that  the 
disease  has  a  laryngeal  onset, — though  this  may  happen  also  in  diph- 
theria,— and,  above  all,  the  absence  of  the  Klebs-Loeffler  bacillus  in 
any  shreds  of  membrane  in  the  expectoration.  In  discussing  laryngeal 
diphtheria  the  matter  is  further  examined  into. 

Chronic  Laryngeal  Affections. 

Of  the  chronic  diseases  of  the  larynx,  chronic  inflammation  of 
the  mucous  membrane  and  thickening  and  ulceration  are  the  most 
common. 

Chronic  Laryngitis. — Alteration  of  the  voice,  cough,  and  an 
uneasy  feeling  in  the  larynx  are  the  main  symptoms.  The  cough  is 
at  first  dry,  but  when  of  any  standing  is  followed  by  a  yellowish 
opaque  expectoration.  It  either  presents  nothing  peculiar  in  its  tone, 
or  else  is  harsh  and  barking.  The  breathing  is  little,  if  at  all,  em- 
barrassed, except  when  the  mucous  textures  are  greatly  thickened 
or  ulcerated.  In  that  case  there  is  dyspnoea,  the  respiration  is  apt 
to  be  noisy  and  the  voice  completely  lost,  because  the  vocal  cords 
have  also  suffered.  There  is,  moreover,  considerable  pain  on  press- 
ure ;  the  sputum  is  muco-purulent,  or  else  purulent  and  streaked  with 
blood ;  and  sometimes,  if  the  cartilages  also  be  involved,  fragments  of 
them  are  expectorated,  and  by  the  touch  we  recognize  the  changed 
state  of  the  tube. 

The  symptoms  of  chronic  laryngitis  are  mostly  not  purely  local. 
Chronic  laryngitis  is  frequently,  indeed,  found  to  be  connected  with  a 
broken  constitution,  because  the  inflammation  of  the  larynx,  both  in 
its  simple  and  in  its  ulcerated  form,  is  often  combined  with  tubercu- 
losis, or  with  syphilis.  In  every  patient,  therefore,  suffering  from 
chronic  laryngitis,  we  must  endeavor  to  ascertain  Avhether  either  of 
these  morbid  conditions  is  present.  Chronic  laryngitis  frequently 
turns  out,  on  thorough  examination,  to  be  laryngitis  linked  to  a  serious 
pulmonary  difficulty ;  or  we  detect  ulcers  in  the  pharynx  associated 
with  those  in  the  larynx  and  cicatrices,  and  are  enabled  to  trace  clearly 
the  ravages  of  constitutional  syphilis. 

As  seen  with  the  laryngoscope  in  chronic  laryngitis,  hyperaemia, 
general  or  partial,  is  present,  associated  in  cases  of  long  standing  with 

16 


250  MEDICAL  DIAGNOSIS. 

considerable  and  uniform  swelling  of  the  mucous  membrane ;  the 
vocal  cords  are  often  uneven  at  their  edges,  and  there  may  be,  chiefly 
between  the  arytenoid  cartilages,  superficial  ulcers.  Papillary  growths 
upon  the  edges  of  the  vocal  bands  may  follow  inflammation  or  repeated 
attacks  of  hyperaemia. 

Chronic  laryngitis  is  liable  to  be  mistaken  for  an  aneurism  of  the 
aorta,  or,  more  strictly  speaking,  an  aneurism  of  the  aorta  is  liable  to 
be  regarded  and  treated  as  a  case  of  chronic  laryngitis.  The  distinc- 
tion, as  will  hereafter  be  shown,  is  mainly  made  by  attention  to  the 
physical  signs ;  often  the  paralysis  of  a  vocal  cord  is  of  great  signi- 
ficance. 

Cases  of  functional  or  nervous  aphooiia,  too,  are  sometimes  con- 
founded with  chronic  laryngitis ;  and  it  is  by  no  means  always  easy 
to  avoid  this  error.  The  loss  of  voice  may  be  either  partial  or  com- 
plete. It  not  infrequently  comes  on  without  any  previous  warning ; 
and  this  fact  aids  us  greatly  in  diagnosis.  So  does  the  absence  of 
cough,  of  expectoration,  of  local  pain,  and  of  all  difficulty  in  breath- 
ing ;  for  none  of  these  symptoms  are  commonly  observed  in  aphonia 
which  is  solely  nervous.  One  of  the  causes  of  the  disorder  is  over- 
stimulation of  the  vocal  nerves,  by  straining  the  voice  in  singing  or  in 
speaking.  We  also  meet  with  it  occasioned  by  narcotics  or  by  lead 
poisoning,  and  perhaps  most  frequently  as  a  reflex  manifestation,  due 
to  irritation  of  the  intestines  by  worms,  or  to  a  disorder  of  the  uterine 
system.  In  these  instances  of  nervous  aphonia  the  voice  suddenly 
disappears  and  as  suddenly  reappears,  a  phenomenon  not  unusual  in 
the  aphonia  of  hysteria ;  and  we  may  have  from  impaired,  but  not 
wholly  lost,  power  the  voice  absent  only  for  some  hours  daily.  It  is 
evident  that  in  all  cases  of  nervous  aphonia  the  laryngoscope  will  assist 
us  greatly ;  it  shows  the  true  condition  of  the  parts,  as  regards  both 
their  structure  and  their  mobility.  It  also  aids  us  in  distinguishing 
these  laryngeal  disorders  from  cases  of  aphonia  due  to  want  of  strength 
in  breathing, — to  want  of  power  in  expiration. 

Enlarged  bronchial  and  cervical  glands,  or  an  aneurism  which 
compresses  the  laryngeal  nerves,  also  produce  hoarseness,  and  ulti- 
mately complete  loss  of  voice.  Under  such  circumstances  there  is  a 
short  cough,  attended  often  with  loud  tracheal  rales  ;  and  we  observe 
attacks  of  dyspnoea,  with  a  noisy,  hissing  respiration.  The  practical 
lesson  which  all  such  cases  teach,  is  to  remember  that  the  symptom 
considered  most  characteristic  of  chronic  laryngeal  inflammation — the 
altered  voice — may  occur  when  no  laryngitis  exists  ;  also  to  examine 
with  the  laryngoscope,  and  to  note  the  effect  of  palsy  of  the  muscles, 
the  result  of  nerve-pressure.     In  thoracic  aneurism,  pressure  symp- 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  251 

toms — such  as  dyspnoea  and  altered  voice,  with  paralysis  of  laryn- 
geal'muscles — maybe  produced  either  by  pressure  upon  the  recur- 
rent laryngeal  nerve,  which  on  the  left  side  passes  around  the  arch 
of  the  aorta,  or  upon  the  vagus.  Pressure  upon  the  vagus  will  give 
rise  to  abductor  paralysis  of  the  corresponding  side,  with  adductor 
spasm  of  the  laryngeal  muscles  of  the  opposite  side,  the  spasmodic 
movements  being  intermittent.  Pressure  upon  the  one  recurrent 
nerve  causes  one-sided  abductor  paralysis,  the  degree  of  pressure 
determining  the  amount  of  paralysis  ;  thus,  when  complete,  there  is 
entire  loss  of  voice,  when  incomplete  the  voice  may  be  hoarse,  whis- 
pering, or  unimpaired.  This  condition  of  one-sided  abductor  paralysis 
may  be  caused  by  pressure  from  an  enlarged  cervical  gland,  by  aneu- 
rism of  the  arch  of  the  aorta,  and  by  various  forms  of  mediastinal 
tumors.  Pressure  upon  one  vagus,  inducing  double  adductor  spasm, 
produces  serious  dyspnoea  and  difficult  phonation ;  but  pressure  on 
one  of  the  recurrent  nerves  may  occasion  intermittent  dyspnoea  that 
is  usually  not  troublesome,  and  scarcely  affects  phonation.  Major's 
researches  have  given  us  much  of  this  definite  knowledge. 

Now,  in  the  nervous  forms  of  aphonia  just  mentioned,  with  the 
exception  of  those  caused  by  pressure,  the  loss  of  voice  is  due  to  de- 
ficient power,  and  the  cords  move  sluggishly  or  not  at  all.  When  the 
disorder  reaches  a  high  degree,  we  perceive,  on  looking  into  the 
laryngeal  mirror,  that  the  vocal  cords  do  not  approximate  as  the 
patient  attempts  to  say  a  or  o.  But,  besides  these  cases,  owing  to 
general  want  of  force,  we  find  cases  of  spasm  of  the  tensors  of  the  vocal 
cords  with  most  peculiar,  partially  interrupted  voice  ;  and  of  absolute 
paralysis  of  individual  muscles,  as  of  one  adductor  of  a  cord ;  or  of 
one  or  both  posterior  crico-arytenoids,  or  abductors ;  or  of  the  crico- 
thyroids, or  tensors.  In  some  of  these  there  is  considerable  dyspnoea, 
with  noisy  breathing ;  in  all  the  laryngoscope  affords  the  only  means 
of  diagnosis.  In  paralysis  of  the  external  tensors  of  the  vocal  cords, 
the  crico-thyroid  muscles,  there  is  inability  to  use  the  higher  notes 
with  freedom  ;  the  voice  is  rough  or  entirely  lost,  and  viewed  with 
the  mirror  we  find  a  wavy  outline  of  the  glottis,  convexity  of  the 
upper  surface  of  vocal  bands  on  expiration  and  phonation,  and  slight 
concavity  on  forcible  inspiration.  The  contraction  of  the  muscles, 
which  in  the  healthy  subject  can  be  felt  externally  during  phonation, 
is  completely  absent.  This  form  of  disorder  most  frecjuently  results 
from  overstraining  the  voice  ;  it  may  be  caused  by  cold,^  and  is  apt  to 
be  bilateral.     Palsy  of  the  thyro-epiglottic  muscles  has  its  usual  origin 

^  Major,  Proceed.  Amer.  Laryng.  Assoc,  1892,  p.  10. 


252  MEDICAL  DIAGNOSIS. 

in  diphtheria.  The  epiglottis  stands  erect,  and  does  not  move  during 
attempts  at  deglutition.  In  palsy  of  the  relax ors  of  the  vocal  cords, 
the  thyro-arytenoid  muscles,  the  deep  tones  are  nearly  gone.  It  is 
often  unilateral,  and  comes  mostly  from  overexertion  of  the  voice 
during  catarrhal  laryngitis.  Viewed  in  the  laryngeal  mirror,  the 
edges  of  the  cords  do  not  approach  in  the  median  line,  and  they 
seem  excavated.  In  paralysis  of  the  posterior  crico-arytenoid  mus- 
cles, the  glottis  is  seen  as  a  narrow  slit,  becoming  still  narrower 
during  inspiration.  There  is  no  disturbance  of  voice,  and  scarcely 
any  sign  of  laryngeal  catarrh,  but  there  is  marked  and  noisy  laryn- 
geal dyspnoea.  This  paralysis  of  the  abductors  may  happen  from 
compression  of  the  recurrent  nerves  by  an  organic  stricture  of  the 
oesophagus.^  Alex.  W.  MacCoy  has  reported  three  cases  of  bilateral 
abductor  paralysis  during  or  after  typhoid  fever,  which  he  attributed 
to  degeneration,  the  result  of  the  fever  process,  in  the  posterior  crico- 
arytenoid muscles.^ 

Bilateral  paralysis  of  the  adductors  is  a  common  disorder 
occurring  in  connection  with  locomotor  ataxia  and  affections  of  the 
brain  and  of  the  medulla.  Paralysis  of  the  muscles  of  the  larynx 
occurring  in  typhoid  fever  has  been  observed  by  Mendel  and  Bonlay  ^ 
and  Ludwik  Przedborski.*  It  happens  both  during  the  fever  and  in 
convalescence.  Nearly  all  of  the  muscles  of  the  larynx  may  suffer  in 
this  way ;  the  paralysis  appears  first  in  the  constrictors  of  the  glottis, 
and  spreads  to  the  remaining  adductors ;  finally  the  abductors  are 
affected,  and  ultimately  a  total  palsy  of  the  recurrent  laryngeal  nerve 
is  the  result.  Recovery  of  function  may  follow  in  from  one  to  three 
weeks.  There  is  a  tendency  for  the  affection  to  become  chronic,  yet 
the  prognosis  is  usually  favorable.  When  the  abductors  of  the 
larynx  and  the  posterior  crico-arytenoids  are  both  paralyzed,  the  vocal 
cords  remain  near  the  median  line,  and  do  not  separate  during  the  act 
of  inspiration  ;  such  cases  are  liable  to  perish  from  suffocation  during 
an  attack  of  dyspnoea.  Thomas '°  has  reported  a  case  of  paralysis  of 
both  recurrent  laryngeal  nerves  consecutive  to  typhoid  fever,  which 
he  found  to  be  due  to  diffuse  neuritis.  Unilateral  paralysis  of  the 
adductors  is  more  rare ;  it  accompanies  malignant  disease  of  the 
oesophagus,  aneurism  of  the  aorta,  and,  exceptionally,  metallic  poison- 

^  Case  of  Dujardin,  Annales  des  Maladies  de  TOreille,  1887. 
^  Section  on  Otology  and  Laryngology,  College  of  Physicians  of  Philadelphia, 
Philadelphia  Medical  Journal,  1899. 

^  Archives  Gen.  de  Med.  ;  Revue  de  Laryngologie,  1895. 
*Klin.  Vortrage,  N.  F.,  No.  182,  May,  1897. 
°  Revue  de  Laryngologie,  1893,  No.  20. 


DISEASES  OF  THE  LAEYNX  AND  TRACHEA.  253 

ing,  as  lead  and  arsenic.  It  sometimes  follows  exposure  to  cold,  or 
attends  rheumatism  or  phthisis.  When  met  with  in  connection  with 
paralysis  of  the  same  side  of  palate  or  tongue,  it  is  centric,  at  times 
bulbar.  E.  Fletcher  Ingals  has  described  cases  thought  to  be  hysteri- 
cal in  origin.  We  also  encounter  sensory  neuroses  of  the  larynx,  and 
among  these  hypersesthesia  is  common. 

Chronic  laryngitis,  or  rather  its  chief  symptom,  loss  of  voice,  is  at 
times  feigned;  and  the  deception  may  be  kept  up  for  an  indefinite 
period.  Yet  we  possess,  in  the  use  of  anaesthetics,  the  means  of 
detecting  the  fraud  at  any  moment.  Just  before  the  impostor  falls 
into  the  deep  sleep  produced  by  ether,  or  as  he  is  recovering  from  the 
insensibility  it  occasions,  his  will  no  longer  controls  his  voice,  and  he 
speaks  in  his  natural  tone,  or  even  screams  violently. 

Now,  under  the  term  chronic  laryngitis,  which  formerly,  for  want 
of  more  precise  knowledge,  was  made  to  embrace  most  kinds  of 
chronic  diseases  of  the  larynx,  many  different  morbid  processes  are 
embraced,  the  exact  nature  and  seat  of  which  we  may  discriminate 
by  the  laryngoscope.  Thus,  the  disorder  may  be  wholly,  or  almost 
wholly,  confined  to  the  epiglottis.  We  may  find  this  structure  highly 
congested  and  enlarged ;  we  may  be  able  to  note  that  it  is  pendent, 
nearly  completely  covering  the  glottis ;  and  it  is  frequently  the  seat 
of  ulceration.  The  attending  symptoms  in  any  case  are  those  re- 
garded as  characteristic  of  a  greater  or  less  degree  of  laryngeal 
inflammation.  In  instances  of  ulceration  there  is  soreness  with 
pain  in  swallowing,  hoarseness  and  irritative  cough,  followed  at  times 
by  blood-streaked  expectoration.  The  ulceration  may  terminate  in 
total  destruction  of  the  epiglottis.  A  turban-shaped  swollen  epiglot- 
tis is  often  met  with  in  phthisis  associated  with  pyriform  swelling  of 
the  arytenoids.  Pallor  of  these  structures,  indeed  of  the  whole 
larynx,  is  one  of  the  early  signs  of  pulmonary  tuberculosis,  as  Cohen 
has  pointed  out. 

When  the  vocal  cords  are  affected,  we  recognize  in  the  laryn- 
geal mirror  either  their  reddening  in  part  or  entirely,  or  their  in- 
duration and  thickening,  or  we  observe  oedematous  swelling  in 
and  around  them,  or  their  ulceration ;  and  we  can  usually  detect 
during  breathing  and  phonation  their  impaired  action.  The  in- 
flammatory redness  may  be  only  in  one  cord.  Small  collections 
of  mucus  are  often  found  adhering  to  different  parts  of  the  laryn- 
geal membrane.  Now,  all  these  conditions  are  generally  com- 
bined with  marked  aphonia;  the  voice,  indeed,  may  be  reduced 
to  the  merest  whisper.  Venous  congestion  of  the  larynx  is  so 
rare   an   afl'ection  that  Mackenzie  has  met  with  but   four   cases    of 


254  MEDICAL  DIAGNOSIS. 

it.^  In  making  our  diagnosis  we  must  always  be  careful  to  find  out 
if  the  laryngeal  phenomena  be  not  secondary,  forming  part  of  a  gen- 
eral morbid  state,  such  as  dropsy,  tuberculosis,  syphilis,  or  changes 
in  the  blood.  Chronic  hypertrophy  of  the  ventricular  bands, is  the 
result  of  inflammatory  thickening,  and,  as  Tauber^  proves,  occurs 
mostly  in  those  who  use  the  voice  much  in  their  professional  voca- 
tions. Tiirck  has  given  the  name  of  "  chorditis  tuberosa"  to  a  condi- 
tion of  the  vocal  bands  in  singers,  in  which  are  found  in  the  upper 
plane  of  the  bands  a  peculiar  uneven  surface  and  white  opaque  spots 
as  large  as  poppy-seeds.^  It  has  been  suggested  that  capillary  fibroma 
or  even  malignant  disease  may  have  an  inflammatory  origin. 

Paralysis  of  one  vocal  cord  may  exist,  with  immobility  of  one  side 
of  the  larynx,  and  yet  voice  may  be  preserved ;  the  healthy  cord,  as 
in  cases  narrated  by  Bosworth,  swinging  over  to  the  paralyzed  side, 
so  as  to  make  up  for  the  loss  of  power  on  that  side.  Voice  may  even 
exist,  to  a  restricted  extent,  not  only  without  vocal  cords,  but  after 
entire  extirpation  of  the  larynx,  as  in  the  remarkable  case  reported  by 
J.  SoHs  Cohen,*  in  which  the  larynx  was  removed  for  malignant  growth, 
and  the  trachea  permanently  fixed  in  the  neck.  After  gulping  some 
air  into  the  gullet  and  throat,  the  patient  was  able  to  talk,  and  even  to 
sing,  by  skilfully  using  his  pharyngeal  muscles. 

Alteration  of  the  voice,  mumbling  speech,  as  though  there  were 
some  difficulty  in  closing  the  glottis,  while  the  movements  of  the  vocal 
cords  appear  normal  as  seen  with  the  laryngoscope,  without  true 
aphasia,  is  mentioned  by  John  N.  Mackenzie  as  a  symptom  in  a  case  of 
bulbar  disease.^ 

Diseases  of  the  cartilages  and  of  the  perichondrium  are  most  fre- 
quently encountered  in  connection  with  tuberculosis,  syphilis,  and 
typhoid  fever.  The  affection  often  begins  in  the  submucous  tissue, 
and  the  ulceration  spreads  until  the  cartilaginous  parts  of  the  larynx 
are  involved.  The  arytenoid  cartilages  are  generally  first  attacked ; 
and  portions  of  these  cartilages  may  be  thrown  off  and  expelled.  At 
times  pus  is  formed  which  gives  rise  to  swellings  that  can  be  recog- 
nized by  the  aid  of  the  laryngeal  mirror ;  sometimes  a  displacement 
of  the  cartilages  takes  place,  before  any  portion  of  them  is  completely 
separated,  and  the  most  distressing  and  dangerous  attacks  of  suffoca- 
tion result ;    or  the  perichondritis  may  lead  to  the  development  of 

^  Diseases  of  the  Throat  and  Nose,  vol.  i.,  1880. 

^  Cincinnati  Lancet,  1887. 

^  Klinik  der  Krankheiten  des  Kehlkopfes,  Wein,  1866. 

*  Pharyngeal  Voice,  Transactions  of  the  Amer.  Laryng.  Assoc,  1894. 

^  Transactions  Amer.  Laryng.  Assoc,  New  York,  1891,  p.  6. 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  255 

bone-substance  and  a  constriction  of  the  tube.  In  some  instances  the 
purulent  collection  presses  on  a  vocal  cord,  which,  with  the  laryngo- 
scope, may  seem  to  be  immovable. 

This  instrument  reveals  very  generally  the  ravages  the  disease  has 
committed ;  and  we  are  thus  enabled  to  form  an  opinion  as  to  how 
far  the  destruction  has  progressed,  and  which  of  the  soft  parts  as  well 
as  of  the  cartilages  are  involved.  Leaving  out  the  frequent  perichon- 
dritis and  caries  of  the  cartilages  which  follow  the  deposition  of  tuber- 
cle, we  And  in  laryngeal  phthisis  considerable  swelling  and  ulceration 
of  the  epiglottis,  and  often  semisolid  pyriform  swellings  of  the  ary- 
epigiottic  folds.  The  thickening  is  more  regular  and  uniform  than 
that  of  syphilis,  and  the  tubercular  ulcers  not  large  and  solid  as  in 
this  affection,  but  small  and  numerous,  and  both  vocal  cords  are  in- 
volved ;  while  in  this  as  in  every  other  respect  syphilis  is  more  apt 
to  be  local  and  unilateral.  Tubercle  bacilli  are  found  in  the  discharge 
from  the  laryngeal  ulcer,  and  in  catarrhal  ulceration  the  ulcers  are 
generally  very  superficial  and  on  the  vocal  cords.  The  symptoms  of 
laryngeal  phthisis  are  difficulty  in  breathing  and  in  swallowing,  local 
pain  and  soreness,  a  greatly  altered  or  a  lost  voice,  and  a  distressing, 
harsh  cough,  which  is  followed  at  times  by  purulent  expectoration. 
Besides,  we  find  the  manifestations  of  disease  of  the  lungs.  But  it 
occasionally  happens  that  we  encounter  cases  of  tuberculous  ulcers 
with  abundant  bacilli,  in  which  no  lung  disease  exists  ;  and  it  is  not 
uncommon  to  find  the  tubercular  disease  of  the  larynx  preceding  that 
of  the  lungs.  At  times  we  note  syphilitic  and  tubercular  ulcers  in 
combination.  We  may  also  meet  with  catarrhal  ulcers  where  there 
is  tubercular  disease  of  the  lungs.  A  means  of  diagnosticating  syphi- 
litic affections  of  the  larynx  from  others  has  been  proposed  and  prac- 
tised by  Justus.^  It  is  based  upon  the  fact  that  after  the  use  of  mer- 
cury by  inunction  or  by  hypodermic  injection  in  a  patient  atfected  by 
syphilis,  a  sharp  fall  in  the  percentage  of  haemoglobin  occurs,  within 
the  few  hours  immediately  following  the  introduction  of  the  remedy 
into  the  system.  Later,  the  proportion  of  hsemoglobin  increases  to  a 
point  above  where  it  was  before.  Justus  observed  the  sudden  fall  of 
ten  to  twenty  per  cent,  in  the  haemoglobin,  following  this  use  of  mer- 
cury, in  over  three  hundred  cases  of  syphilis.  No  effect  of  the  kind 
was  observed  when  the  mercury  was  administered  by  the  mouth. 
This  has  been  called  Justus's  test,  and  has  been  found  applicable  to 
cases  of  ulceration  of  the  larynx,  in  which  there  was  a  doubt  as  to  the 
character  of  the  disease. 

^  Virchow's  Archiv,  vol.  cxl.,  also  cxlviii.,  1897. 


256  MEDICAL  DIAGNOSIS. 

The  diagnosis  between  pachydermia  of  the  larynx  and  the  inter- 
arytenoid  tumor  of  phthisis  is  that  in  the  latter  the  swelKng  is  dis- 
tinctly a  tumor,  with  more  or  less  well-defined  margin.  The  color  is 
usually  red  or  pink ;  in  pachydermia  it  is  whitish-gray  or  only  slightly 
pink.^  Ulceration  occurs  in  pachydermia  only  exceptionally  and  as  a 
complication  ;   it  is  common  in  phthisis  of  the  larynx. 

As  the  result  of  disease  of  the  cartilage  and  of  the  perichondrium, 
especially  as  the  result  of  the  process  of  cicatrization,  we  may  have 
stricture  of  the  larynx  and  trachea ;  for  this  is,  in  truth,  the  most 
common  origin  of  laryngeal  stenosis.  The  inspiration  is  prolonged 
and  noisy ;  the  voice  is  generally,  although  not  of  necessity,  affected. 
There  is  dyspncea,  and  with  the  laryngoscope  we  can  see  how  greatly 
the  caliber  of  the  tube  has  been  encroached  upon.  Cicatrization  is 
common  after  syphilis,  but  Cohen's  case^  proves  that  it  may  occur 
spontaneously  also  in  tubercular  ulcerations.  Adhesions  may  be  con- 
genital, a  web-like  membrane  uniting  the  vocal  cords  through  a  part 
of  their  extent,  as  in  a  case  of  Morell  Mackenzie's.  According  to 
Paltauf,^  primary  stenosis  of  the  larynx  may  be  caused  by  scleroma, 
which  may  develop  early  in  the  larynx.  The  diagnosis  depends  upon 
the  detection  of  the  characteristic  minute  structures. 

Ulcers  in  the  posterior  walls  of  the  larynx  giye  rise,  as  a  rule,  to 
distressing  cough.  Tumors  of  the  larynx  and  polypoid  growths  in  its 
interior  have  as  their  symptoms  cough,  altered  voice,  a  steadily  in- 
creasing difficulty  in  breathing,  and  attacks  of  suffocation  for  which 
nothing  in  the  lungs  or  heart  or  great  vessels  accounts.  But  the 
laryngoscope  alone  tells  us  the  true  meaning  of  these  symptoms. 

New  growths  may  occur  in  the  larynx,  of  the  benign  form.  Papil- 
loma, papillary  fibroma,  is  probably  the  most  common ;  myxoma  is 
rare ;  fibromyxoma  and  fibroma  unusual.  Malignant  disease  in 
various  forms  may  affect  the  structures  of  the  larynx.  A  positive 
diagnosis  can  be  made  only  with  the  aid  of  the  microscope.  Yet  the 
detection,  at  the  seat  of  the  larynx,  of  a  growing  tumor,  accompanied 
by  severe  cough,  by  sanious  sputum,  by  signs  of  destruction  of  tissue, 
by  perichondritis  and  exfoliation  of  the  laryngeal  cartilages,  by  hemor- 
rhages, and  by  emaciation,  warrants  the  diagnosis  of  cancer,  whether 
or  not  much  pain  be  present.  This  may  be  confirmed  by  the  subse- 
quent rapid  development  of  the  malignant  disease,  associated  with  a 
musty  odor  of  the  breath,  distress  in  swallowing,  bloody  expectora- 


^  McBride,  Edinburgh  Medical  Journal,  April,  1893. 

2  Amer.  Journ.  Med.  Sci.,  Dec.  1888. 

3  Sajous,  Annual  of  Univ.  Med.  Sci.,  1893. 


DISEASES  OF  THE  LARYNX  AND  TRACHEA.  257 

tioii,  and  cachexia.  In  some  instances  gangrenous  pneumonia  occurs. 
Polypi  in  the  larynx  may  sometimes  be  seen  by  depressing  and  drag- 
ging forward  the  tongue  until  the  epiglottis  is  brought  mto  view.  But 
as  regards  polypi,  or,  indeed,  any  form  of  morbid  growth,  we  possess 
in  the  laryngoscope  the  only  certain  means  of  detecting  them.  These 
laryngeal  growths  vary  much  in  size  and  in  color;  they  are  often 
seated  at  the  anterior  free  edges  of  the  true  cords,  or  still  more  gen- 
erally just  above  or  just  below  their  origin,  and  are,  as  a  rule,  readily 
discerned.  Sometimes  they  may  exist  for  years,  merely  producing 
changes  in  the  voice  and  some  cough,  but  no  very  great  distress  ;  or 
they  may  lead  to  fits  of  strangulation  and  to  sudden  death.  It  is 
impossible  to  be  sure  of  their  nature  without  repeatedly  examining 
portions  of  them.  Papillomas  are  usually  cauliflower-like  or  in 
bunches ;  they  occupy  most  frequently  the  vocal  cords,  while  sar- 
comas  are  oftenest  found  at  the  anterior  portion  of  the  larynx.  Cysts 
of  the  vocal  cords  are  much  rarer  than  other  forms  of  growths ; 
they  sometimes  rupture  spontaneously,  and  the  hoarse  voice  quickly 
clears.^  Myxomata  of  the  larynx  and  the  epiglottis,  according  to  Van 
der  Poel,^  may  be  manifestations  of  pernicious  anaemia.  They  differ 
from  cysts  in  being  a  pure,  gelatinous  growth  characterized  by  stel- 
late fusiform  cells  embedded  in  a  homogeneous,  or  finely  fibrillated, 
soft,  basement  substance.  Many  cases  that  are  classed  as  cysts  would 
come  under  the  head  of  myxoma  if  the  aid  of  the  microscope  had 
been  sought. 

Before  concluding  these  remarks  on  diseases  of  the  larynx,  it  may 
be  thought  necessary  to  point  out  the  differences  between  them  and 
diseases  of  the  trachea.  But  affections  of  the  trachea  need  not  be 
separately  considered.  Lying  between  the  larynx  and  the  bronchi, 
the  trachea  commonly  shares  in  their  disorders.  Thus,  w^e  have 
seen  croup  to  be  a  malady  in  which  both  larynx  and  trachea  are 
involved.  Slight  inflammation  of  the  trachea  occurs  constantly  in 
slight  attacks  of  laryngitis  or  of  bronchitis.  Ulcers  in  the  trachea 
may  exist  without  ulceration  of  the  larynx ;  but  then  they  usually 
escape  detection.  Sometimes,  however,  they  reveal  themselves  by  a 
constant  pain  at  the  lower  portion  of  the  neck  and  the  upper  part  of. 
the  sternum,  joined  to  all  the  symptoms  of  ulceration  of  the  larynx 
except  the  impaired  voice.  Morbid  groroths,  too,  occur  in  the  trachea, 
— cancer,  carcinoma,  syphilitic  growths, — as  they  do  in  the  larynx, 

^  Heinze,  Archives  of  Laryngology,  New  York,  1880. 
^  American  Laryngological  Association,  1890. 


258  MEDICAL  DIAGNOSIS. 

and  the  tube  may  be  altered  in  form  and  in  structure.  Vegetations 
also  form  in  the  trachea  after  tracheotomy.^  We  can  make  use  of  the 
laryngoscope  to  assist  us  in  the  diagnosis  of  any  of  the  forms  of 
tracheal  disease  referred  to.  Yet  the  instrument  is  not  always  a^^ail- 
able ;  for  it  is  only  under  favorable  circumstances  that  the  entire 
extent  of  the  trachea  can  be  seen. 

In  narrowing  of  the  trachea  the  broncliial  tubes  are  also  at  the 
same  time  often  narrowed.  The  stenosis  may  be  caused  by  external 
compression,  as  from  a  goitre,  from  an  aneurism,  or  from  a  mediastinal 
tumor ;  or  the  constriction  may  be  due  to  some  cause,  such  as  new 
formations,  in  the  walls  of  the  tubes.  The  chief  symptoms  are  the 
same  in  either  case  ;  and  they  are,  long-drawn-out  respiratory  acts, 
noisy  breathing,  especially  in  paroxysms,  dyspnoea,  particularly 
marked  in  inspiration,  epigastric  retraction,  feebleness  or  absence  of 
vesicular  murmur,  with  clear  pulmonary  resonance,  loud  wheezing 
heard  with  the  stethoscope  at  or  near  the  place  of  constriction,  and 
voice  slightly,  if  at  all,  impaired.  Tliis,  the  normal  appearance  of  the 
larynx  as  shown  by  the  laryngoscope,  and  the  almost  imperceptible 
motion  of  the  windpipe  during  breathing,^  are  of  great  value  in  dis- 
tinguishing a  tracheal  stenosis  from  a  laryngeal  affection.  A  bronchial 
stenosis  is  chiefly  discriminated  by  the  signs  of  the  constriction  being 
one-sided,  and  attended  with  marked  thrill  of  the  thoracic  wall  of  the 
affected  side,  and  with  loud  sounds  issuing  from  it,  loud  enough  to 
be  heard  at  a  distance.  Subglottic  oedema  may  be  detected  by  the 
laryngoscope  on  deep  inspiration.  Over  the  trachea,  the  tracheal 
breathing  may  have  become  inaudible  in  stenosis  of  both  main 
bronchial  tubes.^ 

^  See  cases  collected  by  Petel,  Des  Polypes  de  la  Trachee,  Paris,  1879. 

^  Gerhardt ;  also  Riegel,  in  Ziemssen's  Cyclopaedia. 

2  Aufrecht,  Deut.  Arch.  f.  klin.  Med.,  Iviii.  4  and  5,  1897,  p.  484. 


CHAPTER   IV. 

DISEASES  OF   THE  CHEST. 

An  examination  of  the  diseases  of  the  chest  must  be  prefaced  by 
a  description  of  the  methods  of  investigation  which  have  given  to 
their  diagnosis  such  certainty.  The  same  methods  may  be  apphed  in 
the  study  of  the  maladies  of  other  parts  of  the  body,  but  they  are  of 
special  service  in  the  recognition  of  thoracic  disorders,  and  will  be 
here,  therefore,  most  appropriately  considered. 

The  discrimination  of  disease  by  the  eye,  the  ear,  the  touch,  in 
fact,  by  the  direct  aid  of  the  senses,  is  called  physical  diagnosis;  the 
signs  thus  ascertained  are  connected  with  perceptible  alterations  in 
the  material  properties  or  physical  nature  of  structures, — such  as 
alterations  in  their  form,  their  density,  or  their  sounds, — and  are 
known  as  physical  signs. 

Physical  signs  are,  then,  the  exponents  of  physical  conditions,  and 
of  nothing  more.  But  as  the  same  physical  conditions  may  occur  in 
various  diseases,  so  may  the  same  physical  signs  occur  in  various  dis- 
eases. An  isolated  sign  is,  therefore,  not  diagnostic  of  any  particular 
malady.  It  reveals  usually  an  anatomical  change ;  but  it  does  not 
determine  the  disorder  occasioning  this  change.  The  subject  may  be 
much  simplified  by  laying  less  stress  on  individual  signs,  and  by  group- 
ing them  together  according  as  their  association  becomes  distinctive 
of  certain  well-marked  physical  states.  Morbid  anatomy  tells  us  in 
what  diseases  these  states  are  commonly  found.  It  is  in  conformity 
\vith  these  views  that  I  shall  attempt  to  delineate  the  signs  of  thoracic 
affections. 

For  the  sake  of  convenience,  the  surface  of  the  chest  has  been 
mapped  out  into  regions.  Various  arrangements  of  these  have  been 
made  by  different  authors.  The  simplest  division  of  the  chest  is  into 
anterior,  posterior,  and  lateral  surfaces.  The  regions  into  which  the 
anterior  surface  may  be,  for  practical  uses,  subdivided,  are  an  upper 
region,  extending  from  just  above  the  clavicle  to  the  fourth  rib,  and  a 
lower  region,  from  the  fourth  rib  downward.  Posteriorly,  also,  there 
are  an  upper  and  a  lower  part  of  the  chest  to  be  specially  examined. 
It  is  hardly  necessary  to  say  that  all  these  regions  are  double, — the 

259 


260  MEDICAL  DIAGNOSIS. 

same  on  each  side  of  the  chest.  Many  more  divisions  are  usually 
made ;  but  they  are  perplexing  to  the  student,  and  of  doubtful  value. 
The  artificial  boundaries  generally  laid  down  are,  indeed,  too  minute, 
and  yet  not  minute  enough ;  they  are  too  minute  for  ordinary  pur- 
poses, not  minute  enough  when  it  is  desirable  to  localize  a  physical 
sign.  Whenever  this  is  requisite,  instead  of  resorting  to  the  names 
of  the  regions  usually  employed,  I  think  it  preferable  to  designate  the 
seat  of  the  sign  with  reference  to  some  fixed  anatomical  point.  This 
may  be  done  for  the  anterior  part  of  the  chest  by  indicating  the  dis- 
tance above  or  below  the  clavicle,  or  near  what  part  of  the  sternum, 
or  at  which  rib,  or  spreading  over  how  many  intercostal  spaces,  the 
sign  in  question  is  perceived.  At  the  posterior  part  of  the  chest,  the 
spinous  ridge  of  the  scapula,  its  lower  angle,  and  the  spinal  column, 
serve  as  landmarks.  For  most  clinical  purposes,  it  is  only  needed  to 
study  the  region  above  the  spinous  process  of  the  scapula,  as  separate 
from  the  space  below.  But  in  some  instances  it  may  be  necessary  to 
notice  the  region  between  the  scapulse,  interscapular,  or  that  extend- 
ing from  the  lower  angle  of  the  bone  to  the  hmits  of  the  chest,  infra- 
scapular. 

Let  us  now  examine  the  different  methods  of  physical  diagnosis, 
particularly  in  their  relation  to  pulmonary  diseases. 


SECTION  I. 

DISEASES    OF    THE    LUNGS. 

The    Different    Methods    of   Physical    Diagnosis,    and    the 
Physical  Signs  of  Pulmonary  Diseases. 

INSPECTION. 

If  the  chest  be  examined  with  the  eye,  we  obtain  an  idea  of  its 
form,  size,  and  movements.  In  health  this  inspection  shows  us  that 
the  two  sides  of  the  chest  are,  to  a  great  extent,  symmetrical  in  form, 
as  well  as  in  size  and  in  movement.  Both  sides  rise  equally  during 
inspiration  and  sink  equally  during  expiration.  On  both  sides  the 
motion  of  inspiration  is  longer  than  that  of  expiration,  and  the  pause 
between  them  extremely  slight. 

This  respiratory  movement  is  visible  over  the  whole  thorax.  In 
males  it  is  most  distinct  at  the  lower  portions  of  the  chest ;  in  females 
it  is  most  perceptilDle  at  the  upper.  In  healthy  adults  the  lungs  ex- 
pand from  sixteen  to  twenty  times  in  a  minute.     In  certain  pulmonary 


DISEASES  OF  THE  LUNGS.  261 

affections,  especially  in  pneumonia,  the  number  of  respirations  often 
exceeds  fifty  in  a  minute.  But  hurried  breathing  and  changed  move- 
ments of  the  thorax  occur  independently  of  diseases  of  the  lung,  as 
in  an  hysterical  paroxysm.  Where  the  diaphragm  does  not  descend, 
as  in  consequence  of  peritonitis  or  of  abdominal  dropsy  or  of  tumors, 
the  breathing  is  rapid,  and  is  perceptible  at  the  upper  parts  of  the 
chest.  Again,  the  thoracic  movements  may  be  distinct  on  one  side 
and  hardly  noticeable  on  the  other,  as  in  pleurisy  or  in  pneumo- 
thorax. Lastly,  as  happens  in  some  cerebral  lesions,  the  motions  of 
the  chest  may  be  very  slow  and  labored,  or  irregular,  or  they  may 
have  apparently  ceased,  and  the  breathing  be  altogether  abdominal. 

The  form  of  the  chest  is  sometimes  strikingly  altered.  Congenital 
malformations  and  curvatures  of  the  spine  modify  it ;  so  do  intra- 
thoracic affections.  Frequently  the  chest  presents  a  retracted  or  an 
expanded  look.  Retraction  denotes  diminished  size  of  the  lung,  and, 
if  one-sided,  is  usually  indicative  either  of  chronic  changes  in  the 
lung-tissue,  as  in  chronic  pneumonia  or  in  tubercular  lungs,  or  of 
false  membranes  v^hich  bind  down  the  lung ;  or  it  is  found  in  a  very 
marked  manner  in  empyema  with  external  opening.  Expansion  of 
the  chest  is  met  with  in  emphysema,  in  pneumothorax,  and  in  pleu- 
ritic effusion.  A  local  or  partial  expansion,  or  bulging,  may  be 
encountered  in  the  latter  disease,  or  it  may  depend  on  thoracic 
tumors,  on  pericardial  effusions,  or  on  hypertrophy  of  the  heart. 

A  mode  of  inspection  of  value  in  certain  cases  is  the  diaphragm 
phenomenon  to  which  Litten  ^  has  called  attention.  In  a  person  lying 
with  his  feet  pointing  towards  a  window,  there  can  be  seen  during 
deep  breathing  a  shadow  from  about  the  seventh  to  the  ninth  rib  ;  it  flits 
down  during  inspiration,  it  ascends  during  expiration.  This  shadow  is 
nearly  or  wholly  absent  when  fluid  or  air  occupies  the  pleural  cavity  ; 
also  in  obliteration  of  the  cavity  by  adhesions  ;  in  intrathoracic  tumors 
at  the  lower  part  of  the  chest ;  in  pneumonias  of  the  lower  lobe,  and  in 
extensive  emphysema  of  the  lungs.  Tumors  under  the  diaphragm  or 
accumulations  of  fluid  in  the  abdomen  do  not  impair  the  sign,  unless 
they  are  very  large,  nor  do  enlargements  of  the  liver  or  spleen.  The 
shadow  phenomenon  becomes  thus  of  much  value  in  distinguishing 
morbid  states  above  from  those  below  the  diaphragm.  Litten  holds 
that  when  the  excursion  of  the  diaphragm  during  forced  breathing  is 
less  than  two  and  a  half  inches  the  condition  is  abnormal.  In  very 
fat  persons  the  shadow  cannot  generally  be  seen  ;  muscular  weakness 
very  decidedly  limits  it.     It  is  also  much  limited  in  phthisis,  as  both 

^  Deutsches  Medicinische  Wochenschrift,  1892. 


262  MEDICAL  DIAGNOSIS. 

Rumpf^  and  Cabot  ^  prove,  but  its  diminution  may  show  only  on  the 
affected  side. 

A  new  and  most  valuable  means  of  inspection  has  been  discovered 
in  the  Rbntgen  light.  These  X-ray  examinations  have  solved  the 
problem  of  looking  under  the  skin  and  making  deep-seated  parts 
visible,  and  of  gmng  us  photographs  for  permanent  study,  while  by 
the  adaptation  of  a  simple  instrument,  the  fluoroscope,  or  by  the 
fluoroscope  screen,  we  can  do  so  more  quickly  and  see  the  parts  in 
motion.  There  are  immense  possibilities  in  this  new  mode  of  in- 
spection ;  and  while,  thus  far,  it  has  proved  itself  of  the  greatest  use 
to  surgery  in  detecting,  for  instance,  changes  in  the  bones,  fractures, 
dislocations,  and  foreign  bodies,  it  has  also  shown  its  value  in  medi- 
cine. Among  its  contributions  to  this  we  may  note  the  information 
it  gives  us  concerning  rickets,  gouty  deposits  about  the  joints  and 
under  the  skin,  rheumatoid  arthritis,  the  presence  of  renal  calculi. 
Very  valuable  is  the  added  insight  gained  by  X-ray  examinations  in 
diseases  of  the  lungs  and  heart,  especially  in  giving  us  accurate  in- 
formation as  to  the  size  and  movements  of  the  latter.  In  the  recog- 
nition, too,  of  arteriosclerosis  and  of  thoracic  as  well  as  abdominal 
aneurism,  the  rays  have  proved  themselves  of  the  greatest  use,  par- 
ticularly as  they  have  enabled  us  to  detect  them  in  the  early  stages. 

As  regards  the  lungs,  we  have  gained  much  precise  topographical  as 
well  as  pathological  knowledge.^  The  exact  relations  of  the  bronchial 
tree  to  both  the  posterior  and  anterior  thoracic  walls  have  been  clearly 
ascertained  by  skiagraphy.*  On  the  posterior  wall  in  the  adult  the 
course  of  the  left  bronchus  is  found  to  be  from  a  point  to  the  right  of 
the  fourth  thoracic  spine  to  a  point  on  the  eighth  rib  three  inches  to 
the  left  of  the  spine ;  the  course  of  the  right  bronchus  to  a  point  on 
the  eighth  rib  two  inches  to  the  right  of  the  spine.  With  reference 
to  the  anterior  wall  of  the  chest,  the  point  of  bifurcation  in  the  adult 
is  just  internal  to  the  junction  of  the  lower  border  of  the  second 
costal  cartilage  with  the  sternum ;  in  children  it  is  opposite  the  third 
chondro-sternal  articulation. 

The  fluoroscope  is  better  for  most  examinations  of  the  lungs  than 
the  X-ray  photograph,  or  skiagraph ;  it  is  much  quicker,  and  shows 
us  the  parts  in  motion.      The  patient  is  best  examined  standing  up. 

^  Berliner  klinische  Wochenschrift,  No.  vi.,  1897. 
2  Medical  News,  April,  1899. 

*  See  cases  published  in  several  valuable  contributions  by  F.  H.  Williams, 
Medical  News,  vol.  Ixxii.  ;  the  American  Journal  of  the  Medical  Sciences,  June, 
1899  ;  also  the  Transactions  of  the  Association  of  American  Physicians,  1897. 

*  Blake,  Amer.  Journ.  Med.  Sci.,  March,  1899. 


^   a 


CO   2 

2  3 


f°  s: 


i=  M 


DISEASES  OF  THE  LUNGS.  263 

The  range  of  the  diaphragm  motion  is  very  readily  studied ;  it  is 
about  two  and  a  half  inches  on  the  right  side,  and  slightly  more  on 
the  left.  In  emphysema  and  in  pleural  adhesions  the  movements  are 
restricted ;  where  an  ejffusion  is  present  the  diaphragm  line  is  oblit- 
erated on  the  side  of  the  effusion.  The  dark  area  tells  us  the  exact 
height  of  the  fluid.  The  lungs  themselves  become  lighter  in  full  in- 
spiration and  darker  in  expiration. 

Tubercular  or  pneumonic  consolidations  are  shown  by  dark  areas. 
But  X-ray  examinations  do  not  give  us  in  these  diseases  any  more 
information  than  obtained  by  the  ordinary  means  of  physical  explora- 
tion, including  the  microscopical  examination  of  the  sputum,  except 
in  the  localization  and  appreciation  of  the  exact  size  of  the  cavity. 
They  are  of  much  more  use  in  pleural  effusions  and  hydro-pneumo- 
thorax,  where  the  waves  made  by  the  action  of  the  heart  in  the  fluid 
may  be  seen.^  In  congestion  and  cedema  of  the  lungs  there  is  a  gen- 
eral shadow  of  uniform  density,  and  it  is  distinguished  from  the  shadow 
of  early  tuberculosis  by  being  on  both  sides  of  the  chest  and  at  the 
lower  part.  To  measure  the  density  of  the  shadows  upon  the  fluoro- 
scopic screen,  an  instrument  named  the  skiameter  has  been  invented 
by  Crane. ^ 

As  regards  the  heart  the  chief  information  we  obtain  is  as  to  its 
size,  exact  position,  and  movements.  The  fluoroscope  or  the  skiagraph 
gives  us  a  much  better  perception  of  its  size  than  percussion,  particu- 
larly in  stout  persons  or  where  there  is  pulmonary  emphysema ;  a 
small  heart  is  also  very  readily  detected.  The  extent  to  which  the 
acts  of  respiration  influence  the  heart  can  be  thoroughly  studied,  and 
a  diminished  motility  is  found  on  deep  inspiration  in  emphysema  and 
in  adherent  pericardium.  In  pericardial  effusion  a  large  dark  area  is 
seen,  in  which  no  pulsation  can  be  detected. 

The  X-rays  have  also  proved  themselves  of  much  use  in  detecting 
narrowing  and  growths  of  the  oesophagus,  as  well  as  locating  foreign 
substances  there.  By  the  introduction  of  bismuth  or  food  into  the 
stomach,  the  size  of  this  organ  can  be  determined  by  the  rays.  They 
have  also  proved  themselves  of  value  in  stenosis  of  the  pylorus  and 
in  new  growths.^  As  yet  we  have  not  obtained  much  aid  from  them 
in  finding  gall-stones,  but  they  have  given  us  brilliant  results  in  the 
detection  of  renal  calculi.* 

^  Williams,  loc.  cit. 

2  Philadelphia  Medical  Monthly  Journal,  March,  1899. 

^  J.  Boas  and  M.  L.  Dorn,  Deutsches  Medicinische  Wochenschrift,  vol.  xxiv. 
*  See  Fripp,  Brit.  Med.  Journ.,  April,  1898  ;  Leonard,  Therap.  Gazette,  March, 
1899  ;  also  illustrations  in  this  work  in  the  section  on  Diseases  of  the  Kidneys. 


264 


MEDICAL  DIAGNOSIS. 


Fig 


MENSURATIOX. 

To  measure  the  circumference  of  the  chest  or  of  the  abdomen,  or 
to  ascertam  the  distance  from  one  portion  of  the  surface  to  the  other, 
a  graduated  tape  is  all  that  is  required.  To  attain  the  former  object, 
the  spinous  process  of  a  vertebra  is  chosen  as  a  fixed  point,  and  the 
tape  is  thence  passed  round  the  body  to  the  median  line,  first  on 
one  side,  then  on  the  other,  taking  care  that  it  be  applied  evenly  to 
the  skin,  and  that  the  level  of  the  measurement  be  the  same  on  both 
sides.  If  ^ye  wish  to  obtain  the  longitudinal  diameter,  the  line  from 
the  clavicle  to  the  base  of  the  chest  is  taken.  Where  the  chest  is 
deformed,  a  chain  with  links  may  be  used  in  place  of  the  tape. 

In  estmiating  the  size  of  the  chest  in  disease,  it  must  be  borne  in 
mind  that  even  in  health  its  two  sides  vary  widely.  The  half-circle 
on  the  right  side  is,  in  right-handed  persons,  at  least  half  an  inch 
larger  than  the  half-circle  on  the  left.  But  the  measurements,  to  be 
trusted,  must  be  performed  while  the  patient  is  holding  his  breath  in 
expiration.     In  inspiration  the  girth  of  the  chest  is  increased  from 

two  to  three  inches.  In  well-devel- 
oped men  it  measures  at  the  upper 
part,  at  the  level  of  the  nipples,  about 
thirty-three  to  thirty-four  inches  dur- 
ing expu'ation.  Otis,^  as  the  result  of 
one  thousand  measurements,  gives  the 
average  girth  m  men  as  34  inches  in 
repose,  and  36.1  inches  inflated ;  and 
in  well-developed  women  as  29.5  in 
repose  and  31.5  inflated;  while  the 
depth  of  chest  in  repose  in  men  is 
set  down  at  7.5,  and  in  women  at  6.9 
inches. 

If  it  be  desirable  to  ascertain  in  how 
far  the  respiratory  acts  modify  the  di- 
mensions of  the  chest  or  of  the  abdo- 
men, this  may  be  readily  effected  by 
the  ingenious  "  chest-measurer"  of  Sibson,  or  by  the  "  stethometer" 
of  Quam  or  of  Carroll,  or  by  the  instrument  of  Demeny  ;  or  the 
respiratory  cun^es  can  be  traced  and  studied  by  the  atmograph  of 
Burdon  Sanderson,  or  by  the  pneumograph. 

The  transverse  diameter — the  breadth — of  the  chest  may  be  deter- 
mined by  means  of  a  pair  of  calipers,  arranged  specially  for  the  pur- 


The  stethometer  of  Quain.  The  box 
is  placed  on  the  sternum,  and  the  string 
carried  around  the  chest.  One  revolu- 
tion of  the  index,  which  is  moved  by  a 
rack  attached  to  the  striBg,  indicates  an 
inch  of  motion  in  the  chest. 


^  Boston  Medical  and  Surgical  Journal,  April,  1895. 


DISEASES  OF  THE  LUNGS. 


265 


pose ;  and  the  curves  or  flatness  of  the  surface  may  be  ascertained, 
should  it  be  necessary,  by  Alison's  stethogoniometer  (Fig.  19) ;  but  it 
is  rarely  necessarj^  In  fact,  these  minute  measurements,  however 
interesting  to  the  physiologist,  have  not  much  clinical  value. 

Fig.  19. 


The  stethogoniometer  of  Scott  Alison. 


Mensuration  may  be  employed  not  only  to  judge  of  the  size  of  the 
chest  and  of  its  movements,  but  also  to  ascertain  the  amount  of  air 
wliich  is  received  into  the  lungs.  The  instrmiient  used  for  this  object 
is  the  spirometer.  But  the  results  obtained  are  not  on  the  whole  val- 
uable. Sex,  weight,  age,  and  height  have  to  be  taken  into  account. 
For  every  inch  above  five  feet,  eight  cubic  inches  are  to  be  added 
to  the  healthy  standard ;  for  the  height  of  five  feet,  the  breathing  vol- 
ume is  one  hundred  and  seventy-four  cubic  inches.  Otis  ^  estimates 
the  average  lung  capacity  for  height  in  males  between  sixteen  and 
forty  years  of  age  at  twenty-three  cubic  centimetres  for  every  centi- 
metre of  height ;  and  in  women  about  nmeteen  years  of  age  at  fifteen 
cubic  centimetres  for  each  centimetre  of  height.  Brehmer  makes  it 
between  sixteen  and  seventeen  and  a  half  cubic  centimetres.  The 
vital  capacity  may  be  increased  by  practice,  with  the  spirometer,  or  by 
the  use  of  pneumatic  instruments  designed  to  breathe  in  compressed 
air  or  to  breathe  out  into  rarefied  air. 

Waldenburg  measures  the  force  in  respiration  by  a  special  appa- 
ratus, and  has  introduced  pneumatometry  as  a  means  of  diagnosis.  In 
health  the  power  exerted  in  expiration  is  greater  than  in  inspiration 
by  from  twenty  to  thirty  millimetres.  In  some  affections  the  expu'a- 
tory  pressure  is  largely  diminished,  as  in  emphysema  and  asthma, 
while  in  the  forms  of  phthisis  the  force  of  inspiration  is  much  les- 
sened. 

PALPATION. 

Palpation,  or  the  application  of  the  hand,  confirms  the  results 
obtained  by  inspection  and  mensuration  as  to  size,  form,  and  move- 
ments.    It  may,  in  addition,  be  employed  to  determine  spots  of  sore- 

^  Log.  cit. 
17 


266  MEDICAL  DIAGNOSIS. 

ness,  the  density  and  condition  of  tumors,  the  state  of  the  thoracic 
walls,  the  frequency  of  the  breathing,  and  the  action  of  the  heart.  The 
hand  may  further  be  of  service  as  a  means  of  distinguishing  vibra- 
tions produced  by  rhonchi,  rhonchal  fremitus^  or  by  the  voice,  vocal 
fremitus  ;  or  it  may  detect  fluid  by  the  sense  of  fluctuation  it  imparts, 
or  a  roughened  serous  membrane  by  the  friction  fremitus.  When 
both  fluid  and  air  are  present  in  a  large  hollow  space,  by  shaking 
the  patient  a  distinct  vibration  of  the  parietes  is  felt,  accompanied  by 
a  splashing  sound,  known  as  the  Hippocratic  or  succussion  sound. 

Palpation  is  to  be  practised  by  applying  the  palmar  surface  of  one 
or  of  several  fingers  evenly,  and  without  too  much  pressure,  on  the 
part  to  be  examined. 

PERCUSSION. 

By  percussing  or  striking  bodies  we  elicit  sounds  by  which  we 
judge  of  their  composition.  Percussion  was  first  practised  by  striking 
directly  with  the  hand  over  the  organs  to  be  explored ;  a  method 
which  has  given  way  to  mediate  percussion.  The  media  used  to 
receive  the  blow  are  various :  a  disk  or  plate  of  ivory,  or  of  leather ; 
a  piece  of  india-rubber ;  or  the  middle  finger  of  the  left  hand.  The 
finger  answers  best  for  percussion  of  the  chest. 

When  the  finger  is  employed,  it  ought  to  be  applied  with  its  palmar 
surface  firmly  pressed  against  the  chest,  and  as  nearly  parallel  as 
possible  to  the  ribs.     One  or  two  fingers  of  the  other  hand  may  then 

be    used    to   tap   with, — for   the 
FiG^^  finger  is,  for  ordinary  purposes, 

better  than  any  of  the  percussion 
hammers, — the  greatest  attention 
being  paid  to  the  circumstance 
that  the  percussing  finger  strikes 
perpendicularly,  whatever  plex- 
imeter  be  used,  and  not  slant- 
ingly, as  is  too  generally  the  case. 
The     whole     movement     should 

The  pleximeter ;  about  natxiral  size.    It  may  be 

conTeniently  made  of  hard  rubber.  prOCCCd    from    the   Wrist,  and  Only 

from  the  wrist,  and  ought  not  to 
be  too  rapid,  or  unequal,  or  of  great  force.  No  fault  is  so  often  com- 
mitted as  that  of  raising  •  the  finger  used  as  a  pleximeter  from  the 
surface, — thus  obtaining  the  sound  of  the  finger,  and  not  that  of  the 
organ  to  be  percussed, — unless  it  be  the  fault  of  striking  with  great 
force.  Forcible  percussion  is  of  use  only  when  the  sound  of  deep- 
seated  organs  is  to  be  brought  out. 


DISEASES  OF  THE  LUNGS. 


267 


The  main  sounds  elicited  by  percussion 
may  be  designated  as  dull,  clear,  and  tym- 
panitic. Of  course,  these,  like  all  other 
sounds,  may  differ  in  strength,  in  duration, 
and  in  pitch. 

A  didl  sound  denotes  absence  of  air.  It 
is  the  sound  both  of  fluids  and  of  solids.  It 
is,  thus,  the  sound  sent  forth  from  the  air- 
less viscera, — from  the  liver,  spleen,  and 
heart.  When  it  takes  the  place  of  the  pul- 
monary sound,  it  bespeaks  consolidation, 
from  whatever  cause  induced,  or  the  pres- 
ence of  something  which  checks  the  normal 
vibrations  of  the  lung-texture.  Dulness  is 
always  associated  with  an  increased  sense 
of  resistance  to  the  percussing  finger,  and 
over  parts  emitting  it  the  vibrations  of  the 
tuning-fork,  which  Bass  has  introduced  into 
diagnosis,  are  weak,  while  they  are  loud 
over  normal  pulmonary  structure. 

A  dear  sound  is  produced  by  a  series  of 
marked  and  unhindered  vibrations  which 
are  emitted  from  a  substance  containing 
air.  As  thus  defined,  a  clear  sound  evi- 
dently is  yielded  by  percussing  any  air-con- 
taining organ.  But  custom  has  restricted 
the  employment  of  the  term  clear  to  denote 
the  peculiar  resonance  obtained  by  striking 
over  pulmonary  tissue.  When,  therefore,  a 
clear  sound  is  spoken  of,  it  means  a  sound 
having  the  nature  of  that  of  the  lungs,  or 
of  normal  vesicular  or  pulmonary  reso- 
nance. 

A  tympanitic  sound,  on  the  other  hand, 
is  a  non-vesicular  sound,  having  the  char- 
acter of  that  of  the  intestine.  Wherever 
heard,  it  indicates  the  presence  of  quanti- 
ties of  air  in  conditions  similar  to  that  con- 


FiG.  21. 


Fig.  21.— a  serviceable  model  of  a  percussion  hammer; 
not  quite  natural  size.  The  india-rubber  is  screwed  to  the 
ring,  which  has  a  diameter  of  from  five-eighths  to  three-quarters  of  an  inch.  The  metallic  ring 
is  attached  to  a  steel  stem  with  a  very  decided  spring.  The  pointed  portion  of  the  india-rubber  is 
used  to  strike  withion  the  pleximeter. 


268  MEDICAL  DIAGNOSIS. 

tained  in  the  intestine, — namely,  enclosed  in  walls  which  are  yielding, 
but  neither  tense  nor  very  thick.  When  elicited  over  the  chest,  it 
may  be  only  the  transmitted  sound  of  a  distended  stomach  or  colon. 
But  generally  a  tympanitic  sound  over  the  seat  of  the  lungs  is  ex- 
pressive of  emphysema,  or  of  pneumothorax,  or  sometimes  of  a  cavity, 
or  of  oedema  of  the  lungs.  Again,  as  Skoda  has  taught  us,  it  occurs 
in  moderate  pleural  effusions  above  the  level  of  the  liquid.  The  tym- 
panitic sound  is  distinguished  chiefly  from  the  clear  sound  or  pulmo- 
nary resonance  by  its  more  ringing  character  and  its  higher  pitch. 

If  the  cavity  communicate  with  a  large  column  of  air  in  the  bron- 
chial tube,  the  note  on  |)ercussion  varies,  as  pointed  out  by  Wintrich, 
accordingly  as  the  patient  opens  or  closes  his  mouth.  It  is  more 
markedly  tympanitic  and  higher  in  pitch  when  the  mouth  is  wide 
open.  Altering  the  position  from  a  sitting  to  a  horizontal  one,  when 
the  cavity  is  partially  filled  with  fluid,  Gerhardt  has  shown  changes 
the  tympanitic  percussion  note,  and  I  have  observed  it  to  be  markedly 
altered — indeed,  to  disappear — on  a  full  held  inspiration.^ 

As  modifications  of  the  tympanitic  sound  may  be  viewed  the  am- 
pho'rie  or  mefaUiG  sound,  and  the  cracked-pot  or  cracked-metal  sound. 
The  first  of  these  is  a  concentrated  tympanitic  sound  of  raised  pitch, 
and  denotes  a  large  cavity  with  firm,  elastic  walls.  The  second  is  not 
unfrequently  found  associated  with  it.  It  requires  for  its  development 
a  strong,  abrupt  blow  of  the  percussing  finger  while  the  patient  keeps 
his  mouth  open.  The  condition  that  usually  occasions  the  sound  is  a 
cavity  communicating  with  a  bronchial  tube.  It  is  also  met  with  un- 
combined  mth  an  excavation,  as  in  the  bronchitis  of  children,  in 
pleurisy  above  the  seat  of  effusion,  near  a  pericardial  exudation,  in 
emphysema,  and  in  certain  instances  of  pneumothorax.  Indeed,  any 
disorder  in  which  the  chest  walls  remain  very  yielding,  and  in  which 
a  certain  amount  of  air  contained  in  the  lung  or  pleura  is,  by  sudden 
percussion,  forced  into  a  bronchial  tube,  will  occasion  this  cracked- 
metal  sound. 

In  addition  to  the  character  of  all  these  sounds,  we  study  their 
■degree,  or  amount  of  fulness :  such  changes  as  are  expressed  by 
"  more  or  less,"  "  diminished  or  increased."  Thus,  a  clear  sound 
may  be  increased,  owing  to  stronger  vibrations  and  a  larger  quantity 
■of  air,  yet  not  lose  its  distinctive  pulmonary  character,  as  happens 
often,  for  instance,  when .  the  air-cells  are  dilated ;  the  sound  of  the 
large  intestine  is  fuller,  more  tympanitic,  than  that  of  the  small 
intestine,  and  so  forth. 

1  Amer.  Jouru.  Med.  Sci.,  July,  1875. 


DISEASES  OF  THE  LUNGS.  269 

With  changes  in  fulness  or  vohime  of  sound  go  hand  in  hand 
changes  in  its  pitch.  Increased  volume  is  linked  to  lowered  pitch, 
diminished  volume  to  higher  pitch ;  but  so  is  increased  tension. 

To  sum  up  the  chief  results  of  percussion,  as  above  described :, 

Quality,  or  Character  of  Sound, 
Clear  : — Presence  of  air, — as  in  the  lung- tissue. 
Dull  : — Solidification  or  compression. 

Tympanitic  : — -Certain  amount  of  air  enclosed  in  a  structure  or  cavity  the  walls  of 
which  are  not  too  tense. 
Metallic : — Large  hollow  space,  with  firm  but  elastic  walls. 
Cracked-metal  sound : — Usually  a  cavity  communicating  with  a  bronchus. 

Degree,  or  Intensity. 

Any  of  the  sounds  mentioned  may  be  diminished  or  increased  in  intensity  as  the 
conditions  which  produce  them  are  modified. 

Pitch, 
Heightened  or  lowered  as  amount  of  air  or  as  tension  is  altered. 

If  it  be  desirable  to  obtain  a  more  distinct  idea  of  the  sound  than 
can  be  done  by  the  ordinary  method  of  practising  percussion,  it  may 
be  accomplished  by  resorting  to  auscultatory  percussion., — a  method 
that  consists  in  hstening,  with  a  stethoscope  applied  to  the  parietes,  to 
the  sounds  elicited  by  percussion.  It  is  a  means  of  determining  with 
accuracy  the  boundaries  of  organs,  as  of  those  of  the  lungs  or  heart, 
or  of  the  liver  or  spleen,  and  yields  particularly  good  results  when 
carried  out  with  the  double  stethoscope. 

The  percussion  sound  will  also  be  found  to  vary  with  the  respira- 
tory movement,  and  useful  information  may  be  obtained  by  the  ap- 
preciation of  the  note  elicited  by  percussion  while  the  breath  is  held 
after  a  full  inspiration  or  in  a  prolonged  expiration, — a  method  of 
diagnosis  which  I  have  introduced  under  the  name  of  respiratory  per- 
cussion} 

As  a  standard  for  comparison  in  disease,  the  results  of  respiratory 
percussion  in  health  must  be  carefully  determined.  It  will  be  found 
that  in  the  normal  chest,  anteriorly,  a  full  held  inspiration  increases 
the  resonance,  makes  the  sound  fuller,  and  raises  the  pitch ;  but, 
making  allowance  for  the  cardiac  region,  the  resonance  below  the 
apices  is  relatively  less  increased  on  the  left  than  on  the  right  side. 

^  Amer.  Journ.  Med.  Sci.,  July,  1875;  see  also  Friedreich,  Deutsches  Archiv 
fur  klin.  Med. ,  Bd.  xxvi. ,  confirming  these  observations. 


270  MEDICAL  DIAGNOSIS. 

Posteriorly,  we  find  in  tlie  supraspinous  fossae,  and  on  a  line 
towards  the  spine,  that  a  full  inspiration  makes  the  percussion  sound 
fuller  and  raises  the  pitch,  especially  on  the  right  side.  In  the  inter- 
scapular and  infrascapular  regions  the  tone  on  gentle  percussion  is 
distinctly  pulmonarj^  and  the  pitch  moderately  high.  On  the  left  side 
an  admixture  of  tympanitic  resonance  may  be  detected,  particularly  in 
the  infrascapular  region.  The  pitch  is  somewhat  lower  in  the  left 
scapular  and  infrascapular  region  than  in  the  right.  A  full  held  in- 
spiration elevates  the  pitch,  increases  the  resonance  very  much,  and 
makes  the  difference  between  the  sides  less  apparent.  A  held  and 
complete  expiration  greatly  lessens  resonance,  makes  the  tone  less 
full,  and  lowers  the  pitch  on  percussion. 

Percussion  of  the  Healthy  Chest. 

The  sound  elicited  by  striking  a  healthy  chest  differs  in  accord- 
ance with  the  part  percussed.  The  anterior  portion  renders  a  clearer 
sound  than  the  posterior,  on  account  of  the  slighter  thickening  of  the 
thoracic  walls.  But  the  pulmonary  resonance  is  not,  even  anteriorly, 
alike  at  all  parts.  The  portion  of  lung  above  the  cla^icle  yields  a 
sound  which  becomes  somewhat  tympanitic  as  the  trachea  is  ap- 
proached. Percussion  is  difficult  in  this  region,  as  it  is  almost  impos- 
sible to  apply  the  finger  or  pleximeter  closely  to  the  surface.  Over 
the  clavicle  the  sound  sent  forth  is  clear  at  the  centre  of  the  bone  ;  at 
its  scapular  extremity  it  is  duller ;  towards  the  sternum  it  becomes  of 
higher  pitch,  and  mixed  with  the  sound  of  the  bone.  In  the  region 
bounded  above  by  the  clavicle,  and  below  by  the  upper  margin  of 
the  fourth  rib,  the  resonance  is  very  marked.  In  fact,  the  sound  of 
this  region  may  be  taken  as  a  type  of  the  pulmonary  sound :  it  is 
very  clear  and  distinct,  and  but  little  resistance  is  offered  to  the  per- 
cussing finger.  Yet  a  slight  disparity  generally  exists  between  the 
two  sides.  On  the  right  side  the  sound  is  somewhat  less  clear,  shorter, 
and  of  a  higher  pitch,  than  on  the  left.  From  the  fourth  rib  down- 
ward, on  the  right  side,  the  resonance  of  the  lung  on  strong  percus- 
sion, is  found  to  be  slightly  deadened  ;  near  the  sixth  rib  the  perfectly 
dull  sound  indicates  that  the  liver  has  been  reached.  On  the  right 
side,  during  full  inspiration,  the  liver  is  pushed  downward  for  the 
space  of  an  inch  or  more ;  and  the  dull  sound  on  percussion  begins, 
therefore,  lower  down,  and  on  a  line  corresponding  to  the  displace- 
ment of  the  organ. 

On  the  left  side  the  heart  deadens  the  sound  from  the  fom'th  to 
the  sixth  rib,  and,  in  a  transverse  direction,  from  the  sternum  to  the 
nipple.     This  dull  sound  is  lessened  in  extent  during  inspiration,  and 


DISEASES  OF  THE  LUNGS.  271 

in  cases  of  emphysema ;  indeed,  under  any  circumstances  in  which 
the  lung  more  completely  covers  the  heart.  Lower  down,  owing  to 
the  liver  reaching  over  to  the  left  side,  and  to  the  presence  of  the 
spleen  and  a  portion  of  the  stomach,  the  sound  rendered  on  percus- 
sion consists  of  a  mixture  of  the  dull  sound  of  the  solid  viscera  and 
of  the  clear  sound  of  the  lung  with  the  tympanitic  sound  of  the 
stomach.  The  latter  character  of  sound  predominates  when  the 
stomach  is  empty.  Over  the  upper  part  of  the  sternum,  to  the  third 
rib,  the  percussion  sound  is  slightly  tympanitic  ;  at  the  lower  part,  the 
heart  and  liver  cause  this  tympanitic  or  tubular  character  of  sound  to 
give  way  to  a  dull  sound. 

Position  exerts  some  influence  on  the  results  of  percussion.  On 
exchanging  the  recumbent  for  the  erect  posture,  the  pitch  of  the  sound 
on  the  front  of  the  chest  is  raised. 

At  the  jjosterior  portion  of  the  chest  the  sound  varies  materially 
according  to  the. part  percussed.  Directly  on  the  scapulae  the  sound 
is  duller  than  between  the  bones,  or  than  below  their  inferior  angles. 
Beneath  the  scapulae  a  clear  sound  is  emitted  as  far  as  the  lower 
border  of  the  tenth  rib ;  here,  on  the  right  side,  the  dulness  of  the 
liver  begins.  Strong  percussion,  however,  causes  the  dulness  to  be- 
come manifest  higher  up.  On  the  left  side,  below  the  angle  of  the 
scapula,  the  percussion  sound  may  be  tympanitic  if  the  intestine  be 
distended ;  or  it  may  be  rendered  slightly  dull  by  the  spleen.  In 
and  under  the  axilla  the  sound  is  very  clear.  But  on  the  right  side, 
at  the  lower  border  of  the  sixth  rib,  dulness  becomes  perceptible ;  at 
a  corresponding  situation  on  the  left  side,  the  sound  is  clear  or  tym- 
panitic from  distention  of  the  stomach ;  and  at  the  ninth  or  tenth  rib, 
dulness  and  a  sense  of  resistance  to  the  finger  disclose  the  presence  of 

the  spleen. 

AUSCULTATION. 

Auscultation,  or  listening  to  sounds,  informs  us  of  the  play  of 
organs,  and  furnishes  us  with  the  most  trustworthy  means  of  studying 
their  action.  The  method  practised  by  Laennec,  the  discoverer  of 
auscultation,  was  the  mediate,  or  by  the  stethoscope.  Another  method 
has  since  his  time  grown  up, — the  immediate,  or  the  dfrect  application 
of  the  ear  to  the  chest.  For  ordinary  purposes,  this  is  the  best ;  but 
where  it  is  desirable  to  analyze  circumscribed  sounds,  as  in  diseases  of 
the  heart,  the  stethoscope  is  preferable. 

Stethoscopes  are  made  of  various  materials  and  of  different  shapes. 
One  of  moderate  length,  with  an  ear-piece  which  fits  the  pavilion  of 
the  ear,  and  with  the  extremity  not  too  much  expanded,  is  to  be  pre- 
ferred.    The  material  is  of  less  importance.     I  like  best  those  of  gun- 


272 


MEDICAL  DIAGNOSIS. 


Fig.  22. 


metal,  introduced  by  Hawksley.  Of  late  years  double  stethoscopes 
have  been  much  employed.  The  instrument  mvented  by  Cammann, 
of  New  York,  consists  of  two  tubes,  the  extremities  of  which  are 
placed  into  the  ears.  It 
has  since  been  modified  by 
making  the  tubes  attached 
to  the  ear-pieces  of  flexible 
rubber  and  detachable.  But 
it  has  also  been  improved 
by  arranging  it  to  cut  off  ex- 
ternal sounds.^  A  similar 
kind  of  stethoscope  is  the 
differential  stethoscope  of 
Alison,  by  which  each  ear 
receives  simultaneously  the 
sound  from  a  different  re- 
gion. It  is  very  little  used. 
The  most  recent  addi- 
tion to  our  means  of  study- 
ing sounds  is  the  phonen- 
doscope  of  Bianchi.^  It  consists  of  a  metallic 
box  about  the  size  of  a  large  watch,  with  two 
vibrating  plates.  Two  elastic  tubes  serve  as 
conductors,  and,  with  a  small  buttoned  rod 
secured  to  the  lower  plate,  any  point  to  be 
specially  localized  can  be  -examined.  Fig.  24 
shows  the  instrument. 

The  phonendoscope  is  valuable  because  it 
is  readily  applied,  and  does  not  produce  ex- 
aggerated somids.  It  is  of  especial  use  for  the 
outlming  of  organs,  as  a  substitute  for  auscul- 
tatory percussion  as  ordinarily  practised.  Rubbing  the  surface  with 
the  index-finger  over  the  part  to  be  examined  takes  the  place  of  per- 
cussion with  the  finger  or  the  hammer.  For  purposes  of  comparative 
auscultation  it  is  also  valuable,  and  several  persons  can  listen  at  the 
same  time  by  using  different  instruments,  or  by  attaching  more  elastic 
tubes  to  one.  The  phonendoscope  is  of  marked  service  in  studying 
muscular  sounds,  and  of  undoubted  value  in  cardiac  diagnosis.     While 


Hawksley's  stethoscope, 
■with  detached  ear-piece. 


The  double  stethoscope,  original 
model. 


^  Described  by  Knapp,  Medical  Record,  Nov.  9,  1895. 

^  See  Transactions  of  International  Medical  Congress  at  Rome,  1894  ;  Comptes- 
Rendus  de  la  Societe  de  Biologie,  1896. 


DISEASES  OF  THE  LUNGS. 


273 


all  the  claims  made  for  it  have  not  been  substantiated,  I  believe  it  to 
be  a  distinct  addition  to  our  means  of  auscultation,  and  better  than 
the  double  stethoscope.     I  have  certainly  used  it  to  advantage. 
In  auscultating,  the  following  rules  are  to  be  borne  in  mind  : 
1.  Place  yourself  and  your  patient  in  a  position  which  is  the  least 
constraining  and  permits  of  the  most  accurate  application  of  the  ear 

Fig.  24. 


The  phonendoscope,  natural  size ;  the  elastic  tubes  are,  however,  much  shorter  than  in  the  real 
instrument.   The  small  rod  above  is  screwed  on  when  needed  for  piirposes  of  minute  localization. 


or  stethoscope  to  the  surface.     Above  all,  avoid  stooping,. or  having 
the  head  too  low. 

2.  Let  the  chest  be  bare,  or,  what  is  better,  covered  only  with  a 
towel  or  a  thin  shirt. 

3.  If  a  stethoscope  be  employed,  apply  it  closely  to  the  surface, 
but  abstain  from  pressing  with  it.  This  may  be  obviated  by  steadying 
the  instrument,  immediately  above  its  expanded  extremity,  between 
the  thumb  and  the  index-fmger. 

4.  Examine  repeatedly  the  different  portions  of  the  chest,  and 
compare  them  with  one  another  while  the  patient  is  breathing  quietly. 
Making  him  cough  or  draw  a  full  breath  is,  at  times,  of  service,  espe- 
cially the  former,  when  he  does  not  know  how  to  breathe. 


274  MEDICAL   DIAGNOSIS. 

Sounds  of  Respiration  in  Health  and  in  Disease. 

The  ear  applied  over  the  trachea  of  a  healthy  person,  and  subse- 
quently over  the  lungs,  discrmiinates  two  dissimilar  sounds,  which 
may  be  severally  taken  as  starting-points. 

The  first  is  plainly  blowing,  both  in  mspiration  and  in  expiration. 
It  is  heard  over  the  larynx  and  trachea ;  and  in  a  slightly  mochfied 
form,  as  a  less  intense  and  hollow  sound,  at  the  upper  part  of  the 
sternum ;  and  sometimes,  owing  to  the  closeness  of  large  bronchial 
tubes  to  the  surface,  it  is  perceived  between  the  scapulae,  on  a  level 
with  their  ridges.  It  is  occasioned  by  air  passing  through  the  tubes, 
and  is  known  as  the  tuJDular  or  the  bronchial  sound. 

The  sound  over  the  lung-tissue  is  different :  it  is  much  softer,  more 
gradually  formed,  of  lower  pitch,  mainly  inspiratory,  and  almost  im- 
mediately followed  by  a  shorter  and  far  less  distinct  expiration. 
This  is  the  vesicular  murmur, — produced  in  the  finest  bronchial  tubes 
and  air-cells  by  their  expansion  and  contraction.  The  expansion 
gives  rise  to  the  distinct  breezy  inspiration ;  the  noiseless  contraction 
of  the  elastic  walls  of  the  vesicles  and  the  passag-e  of  air  back  into 
the  smaller  bronchial  tulDes  cause  the  short,  indistinct,  sometimes 
almost  inaudible  expiration.  But  the  vesicular  murmur  is  not  exactly 
alike  at  different  parts  of  the  lungs.  It  is,  as  a  rule,  better  marked 
over  the  upper  lobes  than  over  the  lower,  and  more  clearly  defined 
anteriorly  than  posteriorly.  Nor  is  the  sound  of  the  two  lungs  pre- 
cisely the  same  ;  a  disparity  may  generally  be  noticed  at  the  apices. 
Most  authors  describe  the  vesicular  murmur  as  more  intense  on  the 
right  side.  Investigations  instituted  to  determine  this  point  lead  me 
to  agree  with  Flint  that  the  reverse  is  the  case.  More  expiration,  a 
higher  pitch,  therefore  more  of  the  bronchial  element,  is  presented  by 
the  upper  portion  of  the  right  lung ;  but  a  stronger,  more  vesicular 
inspiration  belongs  to  the  left  lung. 

The  murmur  of  the  air-cells,  then,  is  the  sound  which  the  ear 
encounters  when  it  is  placed  over  the  greater  part  of  the  chest. 
Bronchial  respiration  is  constantly  engendered  in  the  tubes  of  the 
lung ;  but,  either  because  it  is  overpowered  by  the  sounds  of  the 
myriads  of  expanding  air-vesicles,  or  because  the  pulmonary  tissue 
is  a  bad  conductor  for  a  deep-seated  sound,  or  perhaps  because  the 
sound  recfuires  consolidated  tissue  for  its  perfect  production,  bronchial 
breathing  is  not  heard  over  the  chest,  except  at  the  very  limited  space 
indicated,  unless  the  action  of  the  air-vesicles  have  been  suppressed. 

Disease,  however,  gives  rise  not  only  to  changes  as  absolute  as 
suppression  of  the  vesicular  murmur  and  its  substitution  by  a  bron- 


DISEASES  OF  THE  LUNGS.  275 

chial  respiration,  but  also  to  certain  modifications  of  the  murmur, 
which  serve  as  valuable  guides  in  diagnosis.  Thus,  the  vesicular 
murmur  may  be  abnormal  in  its  intensity,  or  in  its  rhythm,  or  it  may 
have  lost  some  of  the  elements  of  its  distinctive  character,  such  as  its 
softness. 

Changes  in  the  Vesicular  Murmur. — The  changes  of  the 
murmur  which  are  of  importance  may  be  summed  up  as  follows  : 

|-  Increased,  or  puerile  breathing  ; 
Alteration    in    Intensity <  Diminished,  or  feeble  respiration  ; 

(  Absent  respiration. 

r  Divided  and  jerking  respiration  ; 
Alteration    in    Rhythm <  Alteration  of  length  of  expiration  relatively  to 

I      inspiration. 
Alteration    in    Character Harsh  respiration. 

Intensity. — An  increase  of  the  vesicular  murmur  is  called  supple- 
mentary respiration,  or,  from  its  resemblance  to  the  breathing  of  chil- 
dren, puerile  respiration.  It  depends  upon  an  increased  action  of  the 
air-vesicles  ;  more  air,  or  air  with  greater  force,  entering  them.  The 
sound  is  simply  a  loud,  distinctly  vesicular  respiratif)n ;  both  inspira- 
tion and  expiration  being  augmented  in  duration  and  loudness,  but 
retaining  their  relative  length. 

Peurile  breathing  is  not  in  itself  a  sign  of  any  disease.  It  indicates 
rather  greater  activity  and  energy  of  the  part  over  which  it  is  heard, 
which  activity  makes  up  for  the  deficient  action  of  other  parts.  In  this 
manner  effusions  compressing  one  lung,  one-sided  deposits,  or  obstruc- 
tion of  the  bronchial  tubes  by  secretions,  necessitate  a  supplementary 
respiration  in  the  healthy  portion  of  the  same»lung,  or  in  the  other. 

A  diminution  of  the  vesicular  murmur,  or  feeble  respiration,  con- 
sists in  a  lessening  of  the  whole  sound  without  change  in  its  character. 
But  the  relation  of  inspiration  to  expiration  does  not  remain  the  same 
as  in  health.  In  the  large  majority  of  instances  the  inspiration  suffers 
most,  and  the  expiration  does  not  diminish  in  proportion ;  a  circum- 
stance explained  by  reference  to  the  states  which  occasion  the  di- 
minished vesicular  murmur.  These  are  varied  ;  but  their  causes  may 
be  reduced  to  four : 

1 .  Any  cause  which  obstructs-  the  passage  of  air  and  prevents  it 
from  fully  reaching  the  pulmonary  tissue.  Foreign  bodies  lodged  in 
the  trachea  or  bronchi ;  affections  of  the  larynx  ;  considerable  thick- 
ening of  the  mucous  membrane  of  a  bronchial  tube ;  its  compres- 
sion, or  the  accumulation  in  it  of  secretions,  or  its  contraction  by 
a  spasm, — all  diminish   the   c{uantity  of  the  air  and  the  force  with 


276 


MEDICAL  DIAGNOSIS. 


Fig 


Diagram  illustrative  of  the  main  forms 
of  feeble  respiration :  o,  from  distention  of 
the  cells  in  vesicular -emphysema ;  b,  from 
deposits  in  the  pulmonary  texture ;  c,  from 
a  sohd  body  {d)  lodged  in  a  bronchial  tube, 
which  has  led  to  partial,  or,  in  some  spots, 
to  complete  collapse  of  the  air-vesicles. 


which  it  reaches  the  vesicles,  and  hence  reduce  the  strength  of  the 
murmur. 

2.  Deficient  respiratory  action.    This  may  arise  either  from  general 

debility ;  or  from  impairment  of  the 
nervous  force,  as  in  paralysis  ;  or  from 
local  pain,  as  in  pleurisy  or  in  pleuro- 
dynia. 

3.  Causes  which  interfere  mechan- 
ically with  the  free  expansion  of  the 
air-cells.  Pleuritic  effusions,  by  com- 
pressing the  lung-tissue,  will  of  course 
diminish  the  vesicular  murmur ;  so, 
too,  will  morbid  growths,  or  malfor- 
mation of  the  chest.  Comparatively 
slight  deposits  in  the  pulmonary  tissue 
of  tubercle  or  of  lymph  obliterate  some 
air-cells,  and  prevent  others  from  un- 
folding, and,  by  having  impaired  their 
elasticity,  diminish  their  sound.  The 
same  loss  of  elasticity  happens  in  em- 
physema ;  the  over-distended  cells  cannot  expand  much  more,  they 
are  rigid  and  more  or  less  fixed ;  the  vesicular  murmur  is  therefore 
feeble. 

4.  The  respiratory  murmur  may  be  imperfectly  transmitted  to  the 
ear,  owing  to  intervening  fluids  or  solids.  To  this  category  belongs 
the  enfeebled  murmur  so  constantly  met  with  in  fat  persons. 

As  so  many  conditions  occasion  a  feeble  respiratory  murmur,  it  is 
only  by  association  with 'other  phenomena  that  it  acquires  much  im- 
portance. Taking  the  diseases  in  which  the  sound  is  most  frequently 
found,  it  may  be  stated  that,  if  a  feeble  murmur  be  combined  with 
dulness  on  percussion,  it  signifies  a  tubercular  deposit,  or  a  pleuritic 
effusion :  the  former,  if  at  the  upper,  the  latter,  if  at  the  lower  part  of 
the  lung.  If  it  be  connected  with  increased  clearness  on  percussion, 
distention  of  the  air-cells  is  its  cause.  A  vesicular  murmur,  feeble 
throughout  both  lungs,  with  the  percussion  sound  unaltered,  arises 
from  general  debility,  or  from  obstruction  of  the  upper  air-passages. 
Where  the  feebleness  of  the  murmur  is  found  to  change  from  place  to 
place,  it  is  dependent  upon  a  loose  foreign  body  which  is  shifting  its 
position  in  the  bronchial  tubes.  Joined  to  unwillingness  to  expand 
the  lung,  on  account  of  the  pain  thereby  brought  on,  feeble  respiration 
denotes  pleurodynia  or  beginning  pleurisy. 

An  absence  of  the  vesicular  murmur  is  produced  by  the  same  causes, 


DISEASES  OF  THE  LUNGS.  277 

carried  a  step  farther,  which  occasion  feeble  respiration.  Complete 
obstruction  of  the  tubes  by  foreign  bodies,  extensive  deposits  in  the 
pulmonary  tissue,  or  its  compression  by  large  pleuritic  effusions,  arrest 
the  vesicular  murmur.  But,  practically  speaking,  there  is  only  one 
condition  in  which  we  are  apt  to  find  it  entirely  wanting,  and  that  is 
when,  associated  with  flatness  on  percussion,  the  presence  of  a  large 
collection  of  fluid  in  the  pleura  is  attested.  Extensive  deposits  in  the 
lung-tissue,  tubercular  or  lymphous,  also  suppress  the  sound  of  the 
air-cells ;  but  they  do  not  suppress  all  sound.  The  noise  of  the 
tubes,  the  bronchial  respiration,  then  takes  the  place  of  the  vesicu- 
lar murmur,  and  denotes  the  perfect  consolidation  of  the  pulmonary 
tissue. 

Rhythm. — The  inspiration  and  the  expiration  may  be  altered  as 
regards  their  rhythm.  The  inspiration  may  be  broken  up  into  little 
puffs, — jerking  respiration ;  or  both  inspiration  and  expiration  may 
be  lengthened  or  shortened.  But  neither  lengthening  nor  shortening 
of  the  inspiratory  murmur  has  a  distinct  clinical  value ;  and  jerking 
inspiration,  met  with  as  it  is  in  spasmodic  affections,  in  hysteria,  in 
pleurodynia,  and  in  tubercular  infiltrations,  is  present  under  too  many 
different  circumstances  to  have  by  itself  much  diagnostic  significance. 
But  if  limited  to  the  apex,  it  may  serve  to  excite,  or  aid  in  corrobo- 
rating, a  suspicion  of  tubercular  deposit.  One  modification  of  the 
rhythm  is,  however,  of  decided  importance, — a  marked  increase  in 
the  duration  of  the  expiratory  murmur  while  the  patient  is  breathing 
quietly. 

Prolonged  expiration  denotes  that  the  air  has  difficulty  in  getting 
out  of  the  lung.  It  is  detained  in  consequence  either  of  loss  of  elas- 
ticity of  the  cells,  or  of  an  obstruction  in  the  bronchi.  The  former 
state  may  be  occasioned  by  over-distention  of  the  air-vesicles,  as  in 
emphysema,  or  by  deposits  which  impair  their  contractile  power.  In 
the  first  case,  the  prolonged  expiration  is  associated  with  augmented 
clearness  on  percussion ;  in  the  second,  with  impaired  clearness. 
Where  the  prolonged  expiration  is  met  with  at  the  apex  in  connection 
with  dulness  it  is  most  often  caused  by  a  tubercular  deposit. 

But  a  prolonged  expiration  from  tubercular  or  from  any  other 
kind  of  infiltration  is  not  simply  the  pure,  prolonged  expiration  of 
deficient  elasticity  of  the  air-cells."  It  is  something  more.  The  solid 
material  conducts  a  portion  of  the  sound  of  the  bronchial  tubes  to 
the  ear ;  and  bronchial  breathing  is  nearly  always  best  and  earliest 
perceived  in  expiration.  Thus,  a  prolonged  expiration,  when  joined 
to  dulness  on  percussion  and  to  an  inspiration  still  vesicular,  is  a 
sound  partly  vesicular,  partly  bronchial,  and  may  be'  interpreted  as 


278  MEDICAL  DIAGNOSIS. 

consolidation  of  the  lung-tissue ;  consolidation  not  sufficient  to  have 
obliterated  all  the  air-cells,  but  sufficient  to  have  obliterated  some, 
and  to  have  impaired  the  contractile  power  of  others. 

The  obstacle  to  the  exit  of  the  air  may  reside  wholly  in  the  bron- 
chial tubes.  Such  is  the  source  of  the  prolonged  expiration  when  the 
mucous  membrane  of  the  bronchi  is  swollen.  Not  only  does  this 
condition  cause  the  air  to  be  retained  longer  in  the  air-cells,  but  the 
resistance  to  the  exit  of  the  column  of  air  brings  out  more  of  the 
bronchial  sound.  On  the  whole,  then,  an  accurate  study  of  the  ex- 
piration is  of  decided  value ;  and  it  is  of  importance  to  inquire  into 
the  expiration  separately  from  the  inspiration. 

Character. — A  distinctive  character  of  the  vesicular  murmur  is  its 
softness.  From  the  moment  it  loses  this,  it  begins  to  pass  into  the 
bronchial  sound.  Respiration  which  is  wanting  in  softness  is  termed 
harsh  respiration,  or,  to  modify  slightly  a  term  introduced  by  Flint, 
vesicuh-bronchial.  Harsh  breathing  is,  in  truth,  a  union  of  the  vesicu- 
lar and  bronchial  sounds  ;  it  is  a  vesicular  sound  mixed  with  some  of 
the  qualities  of  a  bronchial  sound, — a  rough  inspiration  devoid  of  all 
the  softness  of  the  normal  respiratory  murmur,  with  a  prolonged, 
somewhat  blowing  expiration.  Any  affection  which,  without  destroy- 
ing the  murmur  of  the  vesicles,  causes  the  sound  in  the  bronchial 
tubes  to  be  produced  with  greater  intensity,  or  to  be  better  trans- 
mitted, will  occasion  harsh  breathing.  Thus,  it  exists  when  the  bron- 
chial membrane  is  swollen,  as  in  bronchitis,  and  still  more  frequently 
in  diseases  which  are  attended  with  compression  of  the  liing-tissue,  or 
with  partial  condensation,  such  as  some  stages  of  the  forms  of  phthisis 
or  of  pneumonia.  Being  a  transition  murmur  to  bronchial,  harsh 
respiration  shares  the  properties  of  the  latter  in  having  its  expiration 
more  developed  than  its  inspiration.  It  is  true,  the  inspiration  alone 
may  be  harsh,  and  the  expiration  not  be  much  changed ;  but  this  is 
uncommon. 

Harsh  respiration  may  be  confounded  with  puerile  respiration, 
with  sonorous  rales,  and  with  bronchial  breathing.  From  the  first  it 
varies  by  its  higher  pitch,  its  harshness,  its  more  distinct  and  blowing 
expiration ;  from  sonorous  rales,  with  which,  however,  it  often  coex- 
ists, by  the  absence  of  all  vibrating  or  musical  character.  From 
bronchial  respiration  harsh  respiration  differs  merely  in  degree  ;  it  is 
mixed  with  more  of  the .  vesicular  sound,  is  less  blowing  in  inspira- 
tion, and,  when  produced  by  condensation,  is  not  associated,  owing 
to  the  smaller  amount  of  deposit  giving  rise  to  it,  with  so  much 
dulness  on  percussion. 

Bronchial  Respiration. — Purely  bronchial  respiration  may  ex- 


DISEASES  OF  THE  LUNGS.  279 

hibit  the  same  modifications  as  the  vesicular  murmur  in  respect  to 
rhythm  and  intensity.  But  neither  its  rhythm  nor  its  intensity  is  of 
significance  ;  its  character  is.  To  hear  well-defined  bronchial  respira- 
tion is,  in  the  majority  of  cases,  to  meet  with  complete  consolidation 
of  the  pulmonary  tissue.  It  is  thus  that  in  extensive  infiltrations  and 
in  hepatization  of  the  lung  we  find  the  bronchial  or  blowing  breath- 
ing so  marked  ;  particularly  so  in  the  latter  morbid  state,  for  the  most 
distinctly  blowing,  or  tubular,  respiration  is  heard  in  pneumonia. 

The  bronchial  breathing  encountered  in  disease  resembles  more 
that  heard  in  health  oyer  the  larynx  or  trachea  than  that  heard  over 
the  larger  bronchial  tubes.  It  entirely  replaces  the  vesicular  sound, 
which  has  for  the  time  being  ceased  to  exist.  It  differs  from  the 
normal  vesicular  murmur  by  its  higher  pitch ;  by  its  occurrence 
•equally  in  inspiration  and  in  expiration;  by  its  blowing  character, 
especially  in  expiration ;  and  by  the  pause  between  inspiration  and 
expiration.  Harsh  respiration  resembles  it  most ;  but  this,  or  vesiculo- 
bronchial respiration,  is,  as  already  stated,  a  transition  from  vesicular 
to  bronchial  breathing. 

Whether  bronchial  respiration  be  owing,  as  Laennec  taught,  to  a 
better  transmission  of  the  sound  of  the  tubes  through  the  solid  lung ; 
or  whether  it  be  produced,  as  Skoda  declared,  by  consonance,  is  not 
of  much  consequence  for  diagnosis.  The  important  practical  fact 
connected  with  this  form  of  respiration  is,  that  it  happens  when  the 
pulmonary  tissue  is  condensed ;  this,  in  the  large  majority  of  cases, 
takes  place  from  exudations  or  deposits,  in  a  small  proportion  only, 
from  compression  by  growths  or  effusions.  At  times  bronchial  respi- 
ration is  also  met  with  in  severe  cases  of  asthma  in  which  the  air 
does  not  expand  the  air-vesicles. 

A  variety  of  bronchial  respiration,  at  least  so  far  as  the  quality  of 
the  sound  determines  the  point,  is  that  significant  sign,  cavernous 
respiration.  This  is  essentially  a  blowing  sound  ;  yet  it  is  not.  always 
distinct  during  both  inspiration  and  expiration,  being  often  only  per- 
ceptible in  the  one,  and  mixed  in  the  other  with  gurgling.  It  is  less 
diffused,  more  hollow,  and  of  much  lower  pitch  than  ordinary  bron- 
chial respiration,  and  is  apt  to  alternate  with  gurgling.  Hollow 
spaces  of  any  kind — from  abscesses,  from  bronchial  dilatation,  from 
breaking-down  cheesy  degeneration,  from  softening  tubercle — give  rise 
to  it.  Its  comparatively  low  pitch  may  c^use  it  to  be  confounded  with 
the  vesicular  murmur.  With  reference  to  this  it  is  only  necessary  to 
recall  that  the  vesicular  murmur  is  devoid  of  all  blowing  quality. 

Amphoric  respiration  is  a  blowing  respiration  engendered  in  a 
large  cavity  with  firm  walls.     Its  peculiar  character  is  owing  to  an 


280  MEDICAL  DIAGNOSIS. 

echo  from  the  walls  of  the  cavity.  It  may  be  humming  and  of  low 
pitch,  or  decidedly  ringing  and  metallic.  Amphoric  or  metalHc  respi- 
ration is  always  indicative  of  a  large  cavity ;  the  sound  is  rarely  met 
with  in  phthisis  ;  much  oftener  is  it  heard  over  the  cavity  which  is 
formed  between  the  layers  of  the  pleura,  by  the  entrance  of  air. 

Another  variety  of  breathing  connected  with  a  cavity  is  the  so- 
called  metamorphosing  breath  sound,  to  which  Seitz  has  called  atten- 
tion. It  occurs  only  in  inspiration,  and  consists  of  a  very  harsh 
sound,  which  lasts  for  about  one-third  of  the  period  of  inspiration, 
when  it  is  continued  as  blowing  respiration,  attended  with  metallic 
echo  or  ordinary  rales.  The  cause  of  the  phenomenon  is  the  air 
entering  through  a  narrow  opening  to  reach  the  csmij.  Flint  ^  re- 
gards this  sign  as  a  variety  of  what  he  calls  broncho-cavernous  respi- 
ration. The  sound  of  expiration  in  broncho-cavernous  breatliing  is 
bronchial,  high  in  pitch,  and  indicates  a  cavity  situated  near  a  portion 
of  consolidated  lung.  In  vesiculo-cavernous  respiration  the  cavity  is 
surrounded  by  comparatively  intact  pulmonary  tissue,  and  this  gives 
an  admixture  of  vesicular  sound. 

Ne'w  or  Adventitious  Sounds. — These  consist  of  sounds  which 
have  no  analogue  in  the  healthy  state,  and  which  are  not,  therefore, 
modifications  of  the  normal  respiration.  Of  this  kind  are  the  rales ; 
crackling ;  the  friction  sound. 

Nearly  all  rales,  or  rhonchi,  are  sounds  which  are  generated  in  the 
air-tubes  by  the  passage  of  air  through  them  when  contracted  or 
when  containing  fluid.  In  the  first  case  are  occasioned  dry,  m  the 
second,  moist  rales.  Rales  may  occur  in  inspiration  or  m  expiration, 
or  during  both  acts.  They  may  obscure  or  entu'ely  take  the  place  of 
the  natural  murmurs.  They  may  have  their  seat  in  the  upper  air- 
tubes,  or  in  any  division  of  the  bronchi.  When  in  the  larynx  or  m 
the  trachea,  they  are  called  tracheal  rales  ;  of  these  the  death-rattle 
is  an  example.  When  in  the  bronchial  tubes,  they  are.  designated 
bronchial  rales  ;  and,  as  this  is  their  most  frequent  situation,  the  term 
rale  means  a  bronchial  rale  unless  the  location  be  specially  indicated. 

Dry  rales  are,  for  the  most  part,  produced  by  the  vibration  of 
thick  fluids  which  the  air  cannot  break  up,  and  which  temporarily 
narrow  the  caliber  of  the  tube.  When  this  narrowing  exists  in  the 
smaller  bronchial  tuloe,  the  sound  which  results  is  high-pitched, — 
sibilant ;  when  m  the  larger,  .unless  the  caliber  be  much  altered,  it  is 
low-pitched,  more  musical, — sonorous.  A  similar  difference  is  ob- 
served with  reference  to  the  moist  or  bulibling  sounds.     When  the 

^  Lectures  on  Physical  Exploration  of  the  Lungs,  1882. 


DISEASES  OF  THE  LUNGS. 


.281 


fluid  is  thin,  whether  it  be  mucus,  blood,  or  serum,  and  breaks  up 
into  large  bubbles,  large  bubbling  sounds  are  occasioned  ;  when  it 
separates  into  small  bubbles,  small  bubbling  sounds  are  the  conse- 
quence.    The  latter,  for  obvious  reasons,  generally  take  place  in  the 

smaller  tubes. 

Fig.  26. 


Large 
bubbling. 


Small 
bubbUna 


Sonorous. 


Sibilant. 


Crepitant. 


Diagram  illustrative  of  rales.  The  narrowing  in  one  division  of  the  tube  gives  rise  to  dry, ""the 
fluid  in  the  other  to  moist,  rftles.  The  rfiles  at  the  termination  of  the  tube  and  in  the  air-vesicles 
are  the  crepitant  or  vesicular  rales. 

Neither  dry  nor  moist  rales  are  persistent,  but  vary  in  intensity, 
or  shift  their  position,  as  the  air  drives  the  liquid  which  gives  rise  to 
them  before  it.  Dry  rales  are  particularly  prone  to  be  dislodged  by 
coughing.  When  they  are  uninfluenced  by  the  act  of  breathing  or  of 
coughing,  they  do  not  depend  upon  the  presence  of  secretions,  but 
upon  a  narrowing  of  the  air-tul3es  from  the  pressure  of  surrounding 
tumors,  or  from  a  fold  of  thickened  mucous  membrane,  or  by  a  spasm. 

It  has  just  been  stated  that  rales  are,  for  the  most  part,  produced 
in  the  bronchi  by  the  passage  of  air  through  fluids  there  contained. 
This  is  their  most  frequent  seat ;"  but  they  are  not  limited  to  the 
tubes.  Similar  conditions  may  give  rise  to  rales  in  other  places.  We 
find  liquids  in  cavities  breaking  up  into  large,  sharply  defined,  bubbling 
rales,  the  so-termed  cavernous  rale, — gurgling;  or  having  in  cavities 
of  considerable  size  a  ringing  metallic  character  ;  and  again,  the  pres- 
ence of  fluid  in  the  air-cells  occasions  a  minute  rale,  the  crejntant. 


282  MEDICAL   DIAGNOSIS. 

This  vesicular  rale,  or  crepitation,  is  a  very  fine  sound,  or  rather  a 
series  of  very  fine  uniform  sounds,  occurring  in  puffs,  and  limited  to 
inspiration.  It  resembles  the  noise  occasioned  by  throwing  salt  on 
the  fire.  Its  name  indicates  its  seat.  It  is  caused  by  the  agitation  of 
fluid  in  the  air-cells  or  in  the  finest  extremities  of  the  bronchial 
tubes  ;  or,  to  adopt  a  view  now  held  by  many,  by  the  forcing  open 
during  inspiration  of  the  air-cells  agglutinated  by  the  exuded  lymph. 
The  first  stage  of  acute  pneumonia  is  the  state  in  which  this  rale 
is  mostly  engendered. 

The  rales,  including  crackling,  may  be  thus  grouped  : 

Dry    or    vibrating  f  Low-pitched  (sonorous). 

sounds.  1  High-pitched  (sibilant). 

Moist  or  bubbling  |  Large  bubbling  (mucous). 

sounds.  1  Small  bubbling  (subcrepitant) . 


Bronchial  Rales. 


-jT  -d'^  f  Crepitation. 

VESICULAR  Rales.      ■{         ^ 

1  CrackUng  (?). 

RiLE  OF  Cavities.   {  follow  bubbUng,  or  gurgling. 
(  Metallic  rales. 

Crackling  is  a  sign  closely  connected  with  rales,  and,  though  its 
mechanism  is  undecided,  it  is  regarded  as  a  rale.  It  consists  of  a  few 
fine  and  readily  discerned  crackling  sounds  which  happen  generally 
in  cases  of  pulmonary  tubercle,  of  which,  therefore,  they  are  consid- 
ered as  diagnostic. 

The  distinction  between  crackling  and  the  crepitant  rale  is  puz- 
zling. The  chief  difference  is  in  the  number  of  the  sounds.  Crackling 
is  a  few  fine  sounds  limited  to  inspu-ation,  and  heard  commonly  at 
the  apex  of  the  lung.  Crepitation  is  a  number  of  fine  sounds  limited 
to  inspiration,  but  more  diffuse,  and  heard  generally  at  the  base.  The 
sound  is  similar  because  the  conditions  giving  rise  to  it  are  similar. 
Both  depend  upon  tenacious  fliiid  or  semifluid  matter  in  the  ultimate 
structure  of  the  lung :  in  the  one  case  it  is  tubercle  or  cheesy  degen- 
eration, in  the  other  usually  the  exudation  of  beginning  inflammation. 
The  crackling  which  indicates  softening,  as  of  tubercle, — called  by 
some  authors  moist  crackling,  by  others  clicking, — is  a  succession  of 
sounds  like  small  moist  rales,  only  less  liquid  than  these,  because 
breaking-up  tubercle  is  not  very  fluid.  When  cavities  form,  and  the 
fluid  matter  in  them  is  agitated  by  the  mgress  and  egress  of  air,  the 
large  bubbling,  ringing .  rale  of  cavities,  or  gurgling,  is  occasioned. 
Dry  crackling,  moist  crackling,  and  gurgling  accord  then  with  the 
crepitant  rale,  small  bubbling,  and  large  bubbling  sounds,  and  happen 
in  the  progressive  stages  of  infiltration  and  softening  of  deposits,  and 
generally  in  those  of  a  tubercular  nature. 


DISEASES  OF  THE  LUNGS.  283 

Pleural  friction,  or  the  sound  due  to  the  rubbing  together  of  rough- 
ened pleural  surfaces,  consists  of  a  number  of  abrupt  superficial  noises 
heard  in  inspiration  and  expiration,  rarely  in  either  alone.  Its  seat  is 
not  usually  extended,  for  it  is,  as  a  rule,  only  audible  over  portions  of 
the  lower  part  of  one  side  of  the  chest.  Sometimes  it  is  so  creaking  and 
intense  as  to  be  distinctly  perceptible  to  the  hand  as  well  as  readily 
recognizable  by  the  ear.  But  it  may  be  so  much  like  crepitation  that 
even  long  practice  in  auscultation  will  not  enable  us  to  determine  at 
once  whether  the  fine  sounds  we  hear  are  the  friction  of  a  roughened 
pleura,  or  the  vesicular  rales  of  an  inflamed  lung. 

Nor  is  it,  in  some  cases,  less  perplexing  to  discriminate  between 
fine  friction  sounds  and  fine  moist  rales.  By  the  sound  alone  it  is 
often  mipossible  ;  concomitant  phenomena  must  be  taken  into  account. 
A  friction  sound  is  mostly  confined  to  a  smaller  space,  and  is  unin- 
fluenced by  cough ;  while  cough  changes  the  position  and  the  distinct- 
ness of .  rales.  Yet  even  this  rule  is  not  absolute.  A  fine  friction 
sound  may  be  temporarily  increased  during  the  deep  breathing  which 
follows  the  act  of  coughing ;  on  the  other  hand,  the  influence  which 
cough  exerts  on  the  small  moist  rale  is  not  so  great  as  on  the  largei 
bubbling  sound.  As  for  the  more  marked  character  of  moisture  which 
a  rale  is  said  to  possess,  that  only  aids  us  in  some  cases.  The  features 
most  at  variance  between  the  friction  sound  and  crepitant  rales  are : 
that  the  friction  phenomena  are  not  strictly  limited  to  inspiration  as 
are  the  vesicular  rales,  are  not  seldom  coarser  in  expiration  than 
in  inspiration,  are  less  uniform,  and  that  their  seat  is  more  cir- 
cumscribed. Their  production  nearer  to  the  ear  may  assist  us,  but 
does  not  always.  The  reason  why  some  of  the  finer  friction  sounds 
resemble  so  closely  fine  moist  rales  or  crepitation  is  apparent  when 
we  reflect  that  the  irregularities  in  the  pleura  may  be  slight,  and  be 
surrounded  by  fluid  which  keeps  them  moistened.  Bruen  has  called 
attention  to  the  value  of  making  the  chest  walls  immovable.-^  When 
the  chest  is  fixed,  especially  at  the  lower  two-thirds,  by  the  hand  of 
an  assistant,  and  the  ear  or  the  stethoscope  is  applied  over  the  doubt- 
ful sounds,  they  will  be  found  to  have  disappeared  if  of  pleural  origin, 
but  to  be  still  discernible  if  rales. 

The  creaking  or  grating  varieties  of  friction  are  much  easier  of 
recognition  than  the  finer  forms.'  Their  discrimination  from  rales  is 
readily  affected  by  noticing  the  rubbing  and  harsh  character  they 
possess. 

^  Physical  Diagnosis. 


284  MEDICAIi  DIAGNOSIS. 

Auscultation  of  the  'Voice. 

When  the  ear  is  apphed  to  the  thorax  of  a  healthy  person  who  is 
speaking,  a  confused  hum  is  perceived,  most  distinct  in  adults  who  are 
possessors  of  a  deep  voice,  and  tremulous  in  the  aged.  Now^  the 
normal  vocal  resonance.,  for  by  that  name  the  ill-defined  vibrations  are 
called,  is  more  marked  on  the  right  than  on  the  left  side,  and  corre- 
sponds to  the  vesicular  murmur.  Over  the  bronchial  tubes  a  more 
concentrated  sound  strikes  the  ear.  This,  termed  bronchophony,  ac- 
cords with  bronchial  respiration,  and,  when  detected  over  the  lung, 
denotes,  with  rare  exceptions  hereafter  to  be  referred  to,  the  same  as 
bronchial  respiration, — increased  density  of  pulmonary  tissue  caused 
by  pressure  or  by  deposit.  Any  normal  vocal  resonance  which  is 
augmented  passes  by  degrees  into  bronchophony,  and  has  a  meaning 
simUar  to  it. 

Of  the  sound  known  as  bronchophony  there  are  several  varieties  : 
the  simple  bronchophony  just  explained, — observed  in  pneumonia,  or 
in  any  form  of  consolidation  ;  the  hollow,  cavernous  voice.,  or  pecto- 
riloquy ;  and  the  bleating  variety,  or  cegophony.  The  latter,  indicative 
of  a  thin  layer  of  fluid  between  compressed  lung  and  the  ear,  is  a 
sign  generally  too  transitory  to  be  of  much  diagnostic  value ;  and 
pectoriloquy,  if  by  this  be  understood  what  Laennec  meant, — com- 
plete transmission  of  articulated  words, — is  of  no  special  significance, 
as  it  may  be  met  with  where  no  cavity  exists.  But  if  the  term  be 
applied  to  a  well-defined  chest-voice,  of  hollow  character,  and  heard 
as  such  over  a  comparatively  limited  space,  pectoriloquy  is  a  distinct 
physical  sign,  and  really  deserves  the  name  of  cavernous  voice.  This 
is  particularly  true  of  whispering  pectoriloquy.  Over  large  cavities  the 
voice  is  peculiarly  ringing  and  metallic.  The  conditions  which  produce 
amphoric  or  metallic  voice  are  the  same  as  those  which  occasion  any 
of  the  amphoric  or  metallic  phenomena.  Be  the  respiration  metallic,  be 
the  voice  metallic,  be  the  rales  metallic,  they  are  all  caused  by  a  cavity 
large  enough  and  with  walls  firm  enough  to  reflect,  to  echo  the  sound. 

Bronchophony  and  amphoric  voice  are  instances  of  increase  and 
change  of  character  of  the  normal  vocal  resonance.  A  climinished 
vocal  resonance  occurs  when  the  lung  is  compressed  by  air  or  fluid,  as 
in  pleuritic  eflusions,  or  in  pneumothorax ;  or  when  it  is  greatly  dis- 
tended with  air,  as  in  extreme  cases  of  emphysema.  Clinically  speak- 
ing, the  sign  is  most  often  encountered  in  pleuritic  effusions. 

The  vibrations  of  the  voice  may  be  felt  as  well  as  heard.  The 
vibration  detected  by  placing  the  hand  over  the  thorax  when  the 
patient  speaks,  the  vocal  fremitus,  is,  like  the  voice,  increased  by  all 
consolidation  of  pulmonary  tissue,  and  diminished  by  fluid  or  air  in 
the  pleura.     Its  relations  to  the  voice  are,  however,  not  uniform ;  and 


DISEASES  OF  THE  LUNGS. 


285 


sometimes  with  increased  density  of  the  lung-tissue  there  is  no  in- 
creased fremitus,  although  there  is  increased  chest-voice.  In  women 
the  sign  is  valueless ;  indeed,  its  main  importance  is  derived  from  its 
absence  in  cases  of  pleuritic  effusions.  Like  the  chest-voice,  it  is  most 
marked  on  the  right  side. 

Rales,  when  extensive,  sometimes  cause  a  vibration  to  be  trans- 
mitted to  the  chest  walls,  as  do  the  fluids  in  cavities.  The  former 
phenomenon  is  called  the  bronchial  fremitus^  the  latter  the  cavernous 
fremitus.  A  friction  sound  that  may  be  felt  is  designated  as  the  pleural 
fremitus. 

The  Combination  of  the  Physical  Signs,  and  the  Examination 
of  Patients  affected  with  Disease  of  the  Lungs. 

In  the  preceding  pages  isolated  physical  signs  have  been  discussed. 
But  if  in  the  investigation  of  disease  we  were  to  trust  solely  to  iso- 
lated signs,  our  conclusions  would  be  incomplete  and  unsatisfactory. 
All  the  methods  of  physical  exploration  must  be  employed,  the  results 
obtained  compared  with  one  another,  and  the  attending  symptoms 
carefully  inquired  into  and  brought  into  connection  with  the  physical 
signs,  before  a  diagnosis  is  made.  The  manner  of  investigating  by 
these  methods  has  been  detailed ;  it  need  not  here  be  repeated.  But 
what  may  be  repeated  is,  that  there  are  two  lungs  ;  that  it  is  incumbent 
always  to  explore  both,  and,  as  we  proceed,  to  compare  the  action  of 
one  with  that  of  the  other. 

As  many  of  the  signs  elicited  by  the  various  methods  of  physical 
diagnosis  depend  on  the  same  physical  conditions,  they  may  be  studied 
in  groups.     The  following  will  be  usually  found  to  be  associated : 

Association  of  Physical  Signs. 


Percussion. 

AUSUUJjTATIOJN  Of 

Eespieation. 

^    AUSCUIjTATION 

OF  Voice. 

Vocal  Fremitus 

Physical  Condition. 

Clear 

.    Vesicular 

Normal  vocal 

Unimpaired. 

Lung-tissue  healthy  or  nearly 

murmur  or 

resonance. 

so;    at    any   rate,    no   in- 

its modifica- 

creased   density   of    lung- 

tion. 

tissue  from  deposit  or  from 
pressure. 

'Bronchial, 

Bronchophony. 

Increased. 

Solidification   of  pulmonary 

or  harsh 

structure. 

Dull 

.  \     respiration. 

Absent  respi- 

Absent  voice. 

Diminished  or 

Effusion  into  pleural  sac. 

-    ration. 

absent. 

Tympanitic 

Cavernous  or 

Uncertain ; 

Uncertain  ; 

Increased    quantity    of    air 

feeble  accord- 

cavernous or 

mostly  di- 

within the  chest,  or  air  con- 

ing to  cause. 

diminished. 

minished. 

fined  in  particular  points ; 
states  commonly  due  to  a 
cavity  or  to  over-distention 
of  the  air-cells. 

Amphoric  or 

Amphoric  or 

Amphoric  or 

Mostly  dimin- 

Large    cavity    vith    elastic 

metallic 

metallic. 

metallic. 

ished. 

'  walls. 

Cracked-metal 

Cavernous 

Cavernous 

Uncertain. 

Generally  a  cavity  communi- 

sound  

respiration. 

voice. 

cating  with  a  broncliial 
tube. 

286 


MEDICAL   DIAGNOSIS. 


In  adults  these  plienomena  are  commonly  combined.  In  children. 
however,  their  connection  is  not  so  constant  nor  so  apparent.  Owing 
to  the  extreme  elasticity  of  the  thoracic  walls  and  the  naturally  clearer 
sound  of  the  lungs,  the  relations  of  percussion  to  auscultation  are  not 
the  same  as  in  the  adult.  Dulness.  even  where  the  condition  exists 
for  its  production,  is  rarely  as  marked :  nor  is  compaiison  between 
the  two  sides  of  the  chest  as  valuahle.  since  most  of  the  acute  pul- 
monary affections  of  childhood  are  more  often  douhle  than  those  of 
adolescence.  Auscultation  is  much  more  applicahle  than  percussion. 
The  back  of  the  lungs  should  be  mvarialDly  examined,  and  be  first  lis- 
tened to.  The  position,  too.  in  which  the  child  is  auscultated  should 
vary  with  its  age.  Very  young  children  may  be  examined  either  m  a 
lying  or  sitting  posture  m  the  lap  of  their  nm'ses.  or  may  be  held  in  the 
arms  of  an  attendant,  who  is  chrected  to  present  the  clilferent  parts 
of  the  thorax  successively  to  the  ear  of  the  physician.  From  the 
cry.  when  studied  with  the  ear  applied  to  the  thoracic  wahs.  we  obtain 
the  same  mdications  as  from  the  vocal  resonance. 

Infants  between  two  months  and  Iavo  years  breathe  irregularly, 
and  about  tliirty-five  times  in  a  minute.  Between  the  ages  of  two 
and  six  years  the  average  number  of  respirations  in  the  same  space 
of  tune  is  twenty-three.  The  breathing  is  also  of  a  different  type 
from  that  of  the  adult :  it  is  abdomuial.  and  can  be  more  readily 
counted  by  noting  the  rising  and  shraiking  of  the  aljdomen  than  by 
watching  the  shght  movements  of  the  chest. 

Before  proceeding  to  the  discussion  of  the  symptoms  of  pulmo- 
nary diseases  and  of  the  diseases  themselves,  let  us  group  the  latter 
according  to  their  anatomical  seat. 

Diseases  of  the  Lr>TT5  a>"d  theie..  Covertn'gs. 

(  Of  large-sized  tubes. 
(  Of  capUlary  tabes. 

Ordinary  ckrordc  ca- 
tarrhal form. 
Putrid  bronchitis. 
Fibrinous  bronchitis. 


Inflammation,  or 
Bronchitis  : 


Bro'Chial  Tubes < 


Acute 


Chronic 


Lu^XT-TISs^E < 


Dilatation  : 

Karrowing ; 

Diseases  of  bronchial  glands  ; 

Spasm  of  muscular  fibres  or  asthma. 

Congestion  : 
Hemorrhage  ; 
Apoplexy  .: 
(Edema  : 
CoUapse  : 
i   Hypertrophy  ; 


DISEASES  OF  THE  LUNGS. 


287 


Lung-Tissue 


Pleura  , 


Diseases  of  the  Lungs  and  their  Coverings. — Continued. 

Inflammation,  or  pneumonia,  in  varied  forms  ; 

Induration ; 

Abscess  ; 

Cirrhosis  ; 

Gangrene  ; 

Emphysema  ; 

Tuberculosis,  chronic  and  acute  ; 

Pneumoconiosis  ; 

Cancer  ; 

Deposits,  such  as  syphihtic,  etc.  ; 

Parasites, 
f  Inflammation,  or  pleurisy  ; 

Empyema  ; 

Hydrothorax  ; 

Haemothorax  ; 

Tuberculosis  ; 
I  Malignant  grow^ths. 

Pleura  and  Lung j  Pneumothorax  ;  * 

Perforations  and  fistulous  openings. 

Pleurodynia ; 

Walls  of  Chest -j   Intercostal  neuralgia  ; 

Abscesses,  etc. 


The  Principal  Symptoms  of  Diseases  of  the  Lungs. 

Of  the  symptoms  about  to  be  mentioned,  not  one  belongs  exclu- 
sively to  pulmonary  diseases.  We  have  met  with  some  of  them  in 
studying  laryngeal  complaints  ;  we  shall  meet  with  them  again  in  ex- 
amining the  affections  of  the  heart.  And  in  investigating  them  here 
we  shall  not  view  them  simply  with  reference  to  morbid  states  of  the 
lungs,  but  shall  indicate  their  general  relations  to  diseased  conditions, 
even  at  the  risk  of  discussing  what  might  in  part  be  more  appro- 
priately discussed  elsewhere. 

The  symptoms  which  it  is  proposed  more  specially  to  sift  are 
dyspnoea,  cough,  and  haemoptysis. 

Dyspnoea. — Dyspnoea  means  difficulty  of  breathing.  It  is  accom- 
panied mostly  by  a  sense  of  uneasiness  and  suffocation,  and  by 
increased  frequency  of  the  respiratory  act.  But  increased  frequency 
of  breathing  may  exist  without  -difficult  breathing.  The  respiration 
may  be  slower  than  natural,  yet  laborious. 

Dyspnoea  depends  upon  various  causes.  Feeble  persons  are 
sometimes  troubled  with  it  after  the  slightest  exertion.  It  may  be 
temporarily  produced  by  any  bodily  or  mental  excitement.  It  is  ob- 
served when  the  play  of  the  diaphragm  is  interfered  with,  and  the 


288  MEDICAL  DIAGNOSIS. 

lung  cramped  in  its  expansion.  This  is  its  cause  in  ascites,  in  ab- 
dominal tumors,  and  in  pregnancy.  It  may  occur  in  perverted  inner- 
vation, as  in  hysteria,  or  in  connection  with  cerebral  affections,  from 
want,  of  power  in  the  respiratory  muscles,  or  it  may  be  due  to  morbid 
blood  conditions,  as  in  anaemia,  scurvy,  uraemia,  and  septicaemia.  It 
is,  however,  most  frequently  met  with  as  a  prominent  symptom  of  the 
disorders  of  the  larynx  and  trachea,  or  of  the  heart,  and  in  the  various 
diseases  of  the  lung  and  pleura,  whether  idiopathic  or  secondary. 
Being  common  to  so  many  morbid  states,  it  is  not  diagnostic  of  any. 

Dyspnoea  is  usually  aggravated  by  position.  When  the  patient  lies 
on  his  back,  the  respiration  becomes  more  difficult.  The  form "  of 
dyspnoea  in  which  the  sufferer  is  obliged  to  remain  in  the  erect  pos- 
ture in  order  to  breathe,  is  termed  orilioj^noea.  This  is  witnessed  in 
extensive  pleural  effusions,  in  pneumothorax,  in  oedema  of  the  lung, 
and  in  affections  of  the  mitral  or  tricuspid  valves. 

Dyspnoea  may  come  on  in  paroxysms,  and  constitute  the  only,  or 
certainly  the  principal,  symptom.     This  is  the  case  in  asthma. 

Asthma. — Asthma  consists  mainly  in  a  spasmodic  narrowing  of  the 
bronchial  tubes,  caused  by  contraction  of  their  circular  muscular 
fibres.  Its  chief  symptom  is  distress  in  breathing,  occurring  in  par- 
oxysms, and  attended  with  wheezing.  These  spasms  may  be  preceded 
by  a  feeling  of  suffocation,  or  they  may  come  on  suddenly.  The  pa- 
tient wakes  up  out  of  his  sleep,  finds  himself  wheezing  and  with  a  fit 
of  the  disease  fully  on  him.  He  continues  to  respire  with  great  diffi- 
culty, sits  upright  in  bed,  or  walks  about  the  room  gasping  for  breath. 
His  look  is  anxious,  the  face  pale,  and  the  color  of  the  lips  shows  that 
the  blood  is  not  properly  aerated.  In  spite  of  the  struggle  to  get  air 
into  the  lungs,  the  chest  moves  but  little,  and  when  the  ear  is  placed 
on  it,  no  vesicular  murmur  is  heard,  simply  the  same  loud  wheezing 
that  is  perceptible  to  the  by-standers  ;  or  bronchial  breathmg  at  the 
upper  part  of  the  chest,  or  sonorous  and  sDDilant  rales  are  detected, 
due  for  the  most  part  to  the  narrowing  of  the  bronchial  tubes,  and 
disappearing  with  the  spasm.  These  dry  rales  are  chiefly  expiratory, 
and  the  lungs  are  very  full  of  air,  and  displace  the  diaphragm  down- 
ward by  several  intercostal  spaces.  At  the  end  commonly  of  some 
hours  the  fit  passes  off  with  copious  expectoration,  and  as  suddenly 
as  it  came.  But  it  may  last  for  days,  ameliorating  in  the  daytime, 
exacerbating  at  night,  and  only  ceasing  gradually.  Where  it  fre- 
quently recurs  it  gives  rise  to  marked  emaciation. 

The  exciting  causes  of  these  bronchial  spasms  are  various.  In 
some  persons  there  is  no  apparent  reason  for  the  attack ;  in  others  it 
is  brought  on  by  the  inhalation  of  irritating  fumes  or  of  cUsagreeable 


DISEASES  OF  THE  LUNGS.  289 

vapors.  In  some  it  is  preceded  by  digestive  disorder,  or  by  bronchial 
catarrh ;  in  others,  again,  an  interruption  to  the  free  circulation  of 
blood  in  the  lung,  or  a  disturbance  in  the  sexual  organs  or  in  the  uri- 
nary secretions,  seems  to  occasion  it.  It  is .  not  unusual  to  find,  on 
closely  questioning  patients,  that  for  some  time  prior  to  the  asthmatic 
paroxysm  they  have  passed  a  scanty,  dark-colored  urine.  Dming  the 
attacks  Leyden  found  in  the  sputum  peculiar  crystals,  farther  on  de- 
picted. Another  interesting  fact  connected  with  the  paroxysm  has 
been  pointed  out  by  Curschmann, — the  presence  on  the  turgid, 
swollen  mucous  membrane  of  the  bronchioles  of  a  characteristic 
viscid  exudation.  This  generally  shows  in  the  sputum  in  little  pellets 
that  have  a  spiral  structure,  very  easily  discerned  by  the  microscope. 

Now,  whatever  be  the  exciting  agent  that  calls  the  bronchial  spasm 
into  existence,  the  symptoms  of  the  attack  of  asthma  are  the  result 
of  the  spasm.  Yet  asthma  is  not  often  a  pure  neurosis.  The  seizure 
itself  is  the  expression  of  perverted  nervous  action.  But  there  are 
generally  permanent  conditions  present,  S'Uch  as  disease  of  the  brain 
or  medulla,  of  the  heart,  of  the  lungs,  of  the  ovaries,  of  the  kidneys, 
of  the  stomach,  or  of  the  nose, — as  polypi  or  hypertrophic  rhinitis, — 
which  act  as  constantly  predisposing  causes  to  these  seizures,  and  lead 
to  attacks,  either  by  direct  irritation  of  the  pneumogastric  nerves  or 
through  the  medium  of  the  reflex  system.  Emphysema  especially  is 
a  fruitful  source  of  spasmodic  asthma.  Asthma  has  been  noticed  to 
replace  other  neurotic  affections,  such  as  epilepsy,^ 

The  detection  of  the  causes  inducing  an  asthmatic  fit  may  be  diffi- 
cult ;  but  the  diagnosis  of  the  fit  itself  is  not  so.  No  disease  of  the 
lungs  or  bronchial  tubes  is  likely  to  be  mistaken  for  it,  because  no 
disease  of  either  gives  rise  to  the  same  symptoms.  The  dyspnoea  of 
pleurisy  or  bronchitis  is  not  paroxysmal,  nor  is  it  attended  with  wheez- 
ing. Some  of  the  affections  of  the  larynx  and  trachea  bear  a  nearer 
resemblance  ;  yet  they,  too,  announce  themselves  by  different  symp- 
toms. Asthma  may  be  distinguished  from  croup  by  the  entire  absence 
of  fever,  and  by  its  lacking  the  peculiar  hoarse  voice  and  cough  which 
appertain  to  the  forms  of  this  malady.  The  age  of  the  patient  is 
also  very  different :  asthma  is  as  rare  in  a  child  as  croup  is  in  an 
adult.  (Edema  and  sjjasm  of  the  glottis  differ  from  asthma  by  the 
much  more  markedly  paroxysmal  nature  of  the  difficulty  of  breathing, 
by  the  shorter  duration  of  the  seizures,  and  by  the  absence  of  the 
loud  and  continued  wheezing.  The  sensations  of  the  sufferer,  too, 
indicate  correctly  the  seat  of  the  obstruction.     And  so  they  arc  apt  to 

1  Lancet,  June  10,  1893. 


290  MEDICAL  DIAGNOSIS. 

do  in  some  of  the  paralyses  of  the  vocal  apparatus^  where  noisy  dyspnoea 
happens,  and  is  aggravated  in  paroxysms.  Further,  we  are  aided 
here  by  the  aphonia,  by  the  inspiratory  character  of  the  stridulous 
breathing,  by  the  absence  of  chest  rales,  and  by  the  obvious  lesion 
seen  in  the  laryngeal  mirror,  A  large  goitre  pressing  on  the  trachea 
may  give  rise  to  dyspnoea  and  to  a  noisy  sound  in  breathing ;  but  the 
cause  of  both  is  easily  traced  to  the  tumor  in  the  neck. 

The  most  deceptive  condition  is  when  the  glands  of  the  neck 
enlarge  suddenly  and  press  on  the  trachea.  I  had,  some  time  since, 
a  young  man  under  my  care  for  acute  bronchitis.  He  was  progress- 
ing favorably,  wheij  one  day  he  presented  himself,  breathing  with 
great  difficulty,  and  each  respiration  attended  with  a  noise  like  the 
wheeze  of  asthma.  I  should  have  regarded  him  as  having  been 
attacked  with  asthma  had  I  not,  in  looking  at  his  neck,  detected  the 
group  of  enlarged  glands. 

Marked  dyspnoea  may  be  occasioned  by  the  pressure  of  an  aneu- 
rismal  tumor,  or  by  an  organic  disease  of  the  heart.  But  the  stridor 
and  the  persistent  difficulty  of  respiration  in  the  first,  aggravated 
though  it  may  become  in  paroxysms,  and  the  constant  want  of  breath 
in  the  second,  are  not  likely  to  be  mistaken  for  the  wheezing  and  the 
paroxysmal  dyspnoea  of  asthma.  True  asthmatic  seizures  may  both 
produce  and  be  produced  by  a  disease  of  the  heart.  But  what  is 
called  "  cardiac  asthma"  is  not  often  a  spasm  of  the  bronchial  tubes : 
it  is  usually  only  a  paroxysmal  dyspnoea,  or  a  temporary  increase  of 
the  dyspnoea,  dependent  upon  a  decided  obstruction  to  the  circulation 
in  the  lungs,  and  not  accompanied  by  wheezing. 

So,  too,  renal  asthma  is  only  very  rarely  a  true  broncliial  asthma, 
being  usually  an  aggravated  form  of  dyspnoea  associated  with  chronic 
Bright's  disease.  So-called  thymic  asthma  is  a  severe  dyspnoea  accom- 
panying enlargement  of  the  thymus  gland,  and  aggravated  in  parox- 
ysms.    It  is  especially  met  with  in  children. 

There  is  a  peculiar  form  of  difficulty  of  breathing  connected  with 
a  loss  of  power  in  the  diaphragm.  When  the  disorder  is  fully  devel- 
oped, even  the  slightest  effort  gives  rise  to  a  feeling  of  suffocation  and 
to  accelerated  respiration.  The  voice  is  much  enfeebled.  But  the 
most  significant  sign  of  the  paralysis  is,  that  during  inspiration  the 
epigastrium  and  the  hypochondria  are  depressed,  while  the  chest 
dilates  ;  and  the  converse  takes  place  during  expiration.  If  there  be 
merely  a  lessened  power  of  the  diaphragm,  these  phenomena  are  ob- 
served only  during  forced  breathing ;  a  paralysis  of  one-half  of  the 
muscle  occasions  them  on  one  side  alone.  Duchenne  adds  another 
important  diagnostic  test  of  a  paralyzed  state  of  the  chaphragm, — 


DISEASES  OF  THE  LUNGS.  291 

namely,  that  if  the  phrenic  nerve  be  galvanized,  the  diaphragm  acts 
again  with  proper  strength,  and  during  inspiration  the  abdomen  rises 
simultaneously  with  the  thoracic  walls.  To  discriminate  the  cause 
of  the  impaired  or  lost  muscular  force, — whether  this  be  due  to  a 
lesion  of  the  nervous  system,  or  to  inflammation  of  the  muscle  or  of 
the  adjacent  textures,  whether  produced  by  rheumatism  or  by  lead 
poisoning,  or  originating  in  progressive  muscular  atrophy, — we  have 
to  rely  chiefly  upon  the  history  of  the  case.  In  rheumatism  of  the  dia- 
phragm, an  absence  of  the  vesicular  murmur  over  the  lower  por- 
tions of  the  chest ;  respiration  effected  by  the  upper  ribs  exclusively  ; 
tense,  hard  abdominal  walls ;  want  of  power  to  strain  so  as  to  aid 
the  bladder  or  intestines  in  expelling  their  contents,  with  darting, 
stabbing  pain  from  the  spine  to  the  margin  of  the  ribs  on  each  effort 
to  inspire, — have  been  particularly  noticed.^  In  fatty  degeneration  of 
the  diaphragm^  which  often  coexists  with  a  fatty  heart,  we  find,  in 
its  last  stage,  great  distress  and  difficulty  of  breathing,  and  death  may 
rapidly  follow  the  embarrassed  respiration.^ 

Another  form  of  dyspnoea  is  the  so-called  Cheyne-Stokes  respira- 
tion. It  consists  in  inspirations  at  first  short,  then  deeper  and  more 
and  rnore  labored,  till  the  paroxysm  is  at  its  height ;  then  becoming 
shorter,  and  more  and  more  shallow,  until  the  breathing  is  suspended. 
The  pause  lasts  from  one-quarter  of  a  minute  to  a  minute,  when  the 
respiration  begins  again  in  the  same  manner,  first  faint,  then  a  little 
■stronger,  then  still  stronger,  until  it  reaches  its  height,  when  it  again 
subsides  in  a  descending  scale,  to  end  in  the  same  stand-still.  This 
kind  of  breathing  is  a  very  bad  sign.  It  is  apt  to  happen  when  from 
some  cause  the  supply  of  arterial  blood  is  cut  off  from  the  respiratory 
centre  in  the  medulla,  or  from  this  and  the  adjacent  vasomotor  centre. 
It  is  rare  in  diseases  of  the  lungs,  much  more  common  in  fatty  heart, 
in  disease  of  the  aorta,  in  tubercular  meningitis,  in  apoplexy  and  affec- 
tions compressing  the  medulla,  in  uraemia,  and  in  sunstroke.  It  may 
be  found  in  cases  that  recover,  and  be  of  long  duration.^ 

Cough. — Cough  is  a  sudden  and  violent  expiration,  having  usually 
for  its  object  the  expulsion  of  some  annoying  substance  from  the  air- 
passages.  But  it  may  be  purely  nervous,  and  unconnected  with  the 
presence  of  any  irritating  matter  in  the  respiratory  organs.  There 
are  several  kinds  of  cough  :  according  to  the  amount  of  expectoration, 


^  Chapman.  Boston  Medical  and  Surgical  Journal,  July,  1864. 
^  Callender,  London  Lancet,  Jan.  1867. 

^  As  in  the  case  of  granular  kidney,  reported  in  the  Clinical  Society  Transac- 
tions, vol.  xxiii.,  1890. 


292  MEDICAL  DIAGNOSIS. 

a  cough  is  dry  or  moist ;  according  to  its  origin,  it  is  laryngeal,  tracheal, 
bronchial,  sympathetic,  etc. 

A  dry  cough  is  indicative  of  irritation.  This  is  often  seated  in  the 
larynx  and  the  trachea,  or  in  their  vicinity,  or  in  the  bronchi,  or  in 
the  lung  itself.  An  elongated  uvula,  and  many  of  the  diseases  of  the 
nose  or  the  pharnyx,  give  rise  to  a  dry  cough :  it  happens,  too,  in 
pleurisy  and  in  the  early  stages  of  phthisis.  In  disorders  of  the 
larynx  and  trachea  the  cough  is  attended  with  a  peculiar  shrill  noise, 
or  a  hoarse  sound.  But  the  irritation  may  not  be  situated  at  all  in 
the  respiratory  system.  Affections  of  the  liver,  stomach,  intestine, 
uterus,  or  brain  will  occasion  an  obstinate  dry  cough.  It  is  also  pro- 
duced by  dentition,  by  diseases  of  the  ear,  by  the  presence  of  worms 
in  the  intestinal  canal,  by  disorders  of  the  heart,  and  by  thoracic 
aneurism.  Again,  it  may  be  strictly  nervous.  The  brazen  cough  of 
hysteria  is  dry ;  indeed,  nearly  all  sympathetic  coughs  possess  a  dry 
character. 

A  moist  cough  may  succeed  to  a  dry  cough.  The  moist  cough 
depends,  for  the  most  part,  on  the  presence  of  fluid  in  the  bronchial 
tubes  or  the  lung-structure.  It  attends  bronchitis  with  free  secretion, 
oedema  of  the  lung,  the  more  advanced  stages  of  all  the  forms  of 
phthisis,  and  pneumonia,  when  the  exudation  is  breaking  up.  It  is 
generally  accompanied  by  a  free,  expectoration,  which  varies  in 
appearance  and  amount  with  the  morbid  state  causing  it. 

Cough  is  frequently  preceded  by  a  sensation  of  tickhng  in  the 
larynx,  to  which  the  patient  is  apt  to  refer  his  whole  disorder.  It  is 
much  affected  by  position.  Lying  down  often  increases  its  intensity. 
Sometimes  a  cough  occurs  in  severe  paroxysms.  In  various  laryngeal 
affections,  in  abscess  of  the  lung,  in  consumption,  and  in  bronchial 
phthisis,  such  fits  of  coughing  are  observed.  But  in  no  complaint  are 
they  so  constant  as  in  whooping-cough. 

Wiooping-Cough. — This  is  essentially  a  disease  of  childhood,  and 
the  result  of  an  epidemic  influence  and  of  contagion.  The  peculiar 
spasmodic  cough  succeeds  to  a  catarrh  of  .more  than  a  week's  dura- 
tion. During  the  paroxysms  the  eyes  fill  with  tears,  the  child's  face 
is  injected  and  anxious,  and  its  whole  appearance  shows  how  it  is  suf- 
fering for  want  of  breath.  The  air  in  the  lungs  is  expelled  by  a  series 
of  abrupt  spasmodic  expirations,  when  a  long-drawn  inspiration, 
attended  with  a  whoop,  temporarily  puts  a  stop  to  what  appears  to  be 
threatening  suffocation.  The  rest  is,  however,  short.  The  cough 
recommences,  and  is  again  followed  by  the  loud  whooping  inspiration. 
It  continues  in  this  manner  until,  after  a  copious  expectoration  of 
stringy  mucus,  or  after  vomiting,  the  paroxysm  ceases,  and  a  more 


DISEASES  OF  THE  LUNGS.  293 

lengthened  calm  ensues.  These  fits  of  coughing  repeat  themselves  at 
varied  intervals  during  the  tw^enty-four  hours.  They  are  very  fre- 
quent at  night.  Yet  the  child's  health  remains  good,  in  spite  of  the 
violence  of  the  attacks  and  the  length  of  time  they  are  spread  over. 
The  spasmodic  cough  lasts  for  weeks ;  the  whoop  then  ceases,  the 
cough  loses  its  ringing  sound,  and  gradually  leaves  entirely.  It  is  only 
in  comparatively  rare  instances  that  it  persists,  and  is  followed  by  the 
development  of  tubercles  in  the  lungs  ;  just  as  it  is  only  in  exceptional 
instances  that  bleeding  from  the  nose  or  lungs,  petechise  on  the  fore- 
head, or  ecchymoses  of  the  conjunctivse  happen  during  the  violent 
coughing.  In  about  one-half  the  cases  the  cough  is  violent  enough 
to  produce  ulceration  of  or  around  the  fraenum  linguge,  from  the 
force  with  which  the  tongue  is  propelled  against  the  teeth.  Fre- 
quently the  ulcer  is  covered  with  a  grayish  exudation ;  it  is  never 
noticed  before  the  paroxysmal  stage  is  well  established.  Sugar  is  at 
times  found  in  the  urine.  As  an  early  symptom  of  whooping-cough, 
photophobia  with  dilatation  of  the  pupils  has  been  observed.^  Con- 
vulsions are  in  very  young  children  not  infrequent.  Whooping-cough 
is  often  associated  with  measles. 

An  affection  of  so  long  duration,  marked  by  such  a  peculiar  sign 
as  a  whoop,  is  of  easy  diagnosis.  Yet  there  are  certain  conditions 
with  which  it  may  be  confounded.  In  its  first  stage,  before  the  char- 
acteristic cough  sets  in,  it  may  be  mistaken  for  acute  bronchitis.  There 
is,  indeed,  at  this  period,  no  means  of  distinguishing  between  the  two 
disorders,  except  by  taking  into  account  the  tendency  to  choking,  to 
flushing  of  the  face,  and  to  vomiting  in  whooping-cough  ;  for  it  is  only 
seldom  that  the  cough  possesses  from  the  onset  a  decided  ring.  And 
bronchitis  is  in  fact  the  most  frequent  complication,  or,  to  state  it 
more  accurately,  almost  an  essential  element,  of  the  malady.  It  is 
usually  present  in  a  mild  form  at  the  start;  it  outlasts  the  parox- 
ysmal stage.  At  the  height  of  this,  a  severe  attack  of  acute  bronchitis 
or  of  broncho-pneumonia  may  temporarily  mask  the  special  traits  of 
pertussis.  Again,  occasionally  acute  broncliitis  may  exhilDit  parox- 
ysms of  spasmodic  cough.  But  the  want  of  the  nervous  element  in 
the  disease,  the  absence  of  the  whoop  and  of  the  recurring  flushing,  of 
the  face  as  well  as  of  the  vomiting,  the  dyspnoea  between  the  parox- 
ysms, the  decided  fever,  do  not  permit  us  to  be  long  in  doubt. 

A  disease  less  easy  to  discriminate  from  whooping-cough  is  tuber- 
culization of  the  bronchial  glands,  or  bronchial  phthisis.  It,  too,  pro- 
duces a  ringing  paroxysmal  cough.     It,  too,  occurs  in  children.    There 

^  Huguin,  quoted  in  British  Medical  Journal,  Sept.  26,  1891. 


294  MEDICAL  DIAGNOSIS. 

is,  however,  this  difference  :  the  enlarged  bronchial  glands  are  apt  to 
press  on  the  surrounding  parts.  This  becomes  manifest  by  the  en- 
gorgement of  the  veins  of  the  neck,  by  the  lividity  and  puffiness  of 
the  skin,  by  the  difficulty  in  breathing  and  in  swallowing.  The  char- 
acter of  the  voice,  also,  may  change  ;,  and  yet  there  may  be  no  abnor- 
mal physical  signs  in  the  chest.  But  often  there  is  dulness  on  per- 
cussion between  the  scapulae,  where  the  swollen  bronchial  glands  lie, 
and  impaired  respiration  in  portions  of  the  lung.  The  symptoms  are 
those  of  pulmonary  phthisis,  with  which  the  disease,  indeed,  may  be 
associated :  there  are  emaciation,  and  the  same  loss  of  strength,  the 
same  sweating  at  night,  the  same  hectic  fever,  the  same  tendency  to 
diarrhoea.  At  times  the  affection  of  the  glands  induces  a  caseous 
pneumonia, — in  reality  tubercular.  Now,  when  we  compare  these 
phenomena  with  those  presented  by  whooping-cough,  we  miss  the 
whoop,  the  vomiting  accompanying  the  fits  of  coughing,  the  ulceration 
or  tearing  of  the  fraenum  of  the  tongue, — a  symptom  usual,  at  least,  in 
decided  cases, — the  epidemic  or  contagious  origin,  and  the  distinct 
periods,  first  of  catarrh,  then  of  spasmodic  cough,  then  of  gradual 
decline.  We  see,  on  the  contrary,  an  affection  of  more  gradual  and 
uniform  progress,  which  often  proves  its  existence  by  special  signs, 
among  which  a  venous  hum,  heard  when  the  stethoscope  is  placed 
upon  the  upper  bone  of  the  sternum  while  the  child  bends  back  the 
head,  has  been  particularly  noticed.^ 

When  emaciation,  hectic  fever,  and  marked  cough  are  met  with 
in  the  last  stage  of  whooping-cough,  it  is  always  highly  probable  that 
this  has  been  followed  by  a  tubercular  deposit,  and  finding  tubercle 
bacilli  in  the  sputum  confirms  this  view.  It  is  not  likely  that  such 
cases  will  be  mistaken  for  those  instances  of  pulmonary  consumption 
in  which  violent  paroxysms  of  coughing  occur.  The  age,  the  origin, 
the  history  are  different.  Equally  dissimilar  are  the  history  and  the 
symptoms  in  other  spasmodic  coughs,  such  as  those  of  hysteria  and 
of  some  laryngeal  affections. 

The  Sputum. — The  consistency  of  the  expectoration  varies  very 
much.  When  it  is  viscid  and  tough,  it  contains  a  large  amount  of 
mucus  or  muco-pus,  and  depends  generally  upon  inflammation  or  a 
high  degree  of  irritation  of  the  bronchial  membrane  or  of  the  lung 
parenchyma.  When  it  is  less  tenacious,  it  has  far  less  mucus,  and  a 
preponderance  of  pus.  When  fluid  and  full  of  air,  it  floats  ;  when 
dense  and  without  air,  it  sinks.  Fluid  sputum  forms  a  homogeneous 
mass ;  dense  sputum  assumes  a  round  or  irregularly  round   shape. 

^  Eustace  Smith,  London  Lancet,  Aug.  1875. 


DISEASES  OF  THE  LUNGS.  295 

When  these  purulent  masses  float  in  a  thinner  expectoration,  we  have 
the  coin-shaped  or  nummular  sputum,  so  common  in  instances  of 
pulmonary  cavities. 

The  quantity  of  the  expectoration  varies  greatly  in  different  dis- 
eases of  the  lungs.  In  the  most  acute  stages,  or  in  spreading  inflam- 
mations, it  is  usually  small,  and  increases  as  the  difficulty  lessens. 
In  bronchial  dilatation,  in  pulmonary  abscesses,  especially  when  they 
burst,  and  in  the  voiding  of  a  collection  of  pus  in  the  pleura  through 
the  bronchial  tubes,  the  amount  discharged  is  very  large,  and  consists 
almost  entirely  of  pus. 

The  color  of  the  sputum  depends  a  great  deal  on  its  constituents. 
When  mucous,  it  is  white  ;  when  muco-purulent,  yellowish  or  yel- 
lowish-green ;  when  purulent,  generally  greenish  or  of  a  yellowish- 
green.     It  is  also  tinged  by  bile,  by  pigment,  and  by  blood. 

Sputum  consists  chiefly  of  water,  serum,  albumin,  mucin,  nuclein, 
and  many  salts,  such  as  the  chlorides  of  sodium  and  magnesium,  the 
sulphates  of  sodium  and  calcium,  and  the  phosphates  and  the  car- 
bonates of  sodium,  of  magnesium,  and  of  calcium.  It  has  an  alkaline 
reaction.  In  certain  diseases,  especially  in  putrid  bronchitis  and  in 
gangrene  of  the  lung,  it  contains  ferment  that  acts  like  the  pancreatic 
ferment.^ 

Microscopically  examined  it  exhibits  pavement,  columnar,  and 
alveolar  epithelium,  leucocytes,  blood-globules,  various  forms  of  crys- 
tals, such  as  the  slender  needles  of  the  fatty  acids,  fibrinous  coagula, 
bacteria,  fungi,  and  elastic  fibres.  The  alveolar  epithelium  is  mostly 
of  elliptic  shape,  and  often  shows  little  fat  drops  or  pigment  particles. 
The  fatty  acids  and  the  elastic  fibres  are  encountered  in  diseases  in- 
volving disorganization  of  the  lung-tissue.  Mould  fungi,  forms  of 
leptothrix,  and  sarciuEe'  have  been  specially  noticed.  The  latter  are 
smaller  than  the  sarcinse  ventriculi.  The  fungi  are  most  common 
in  the  sputum  from  cavities,  in  putrid  bronchitis,  and  in  gangrene. 
The  leptothrix  masses  are  readily  recognized  by  their  blue  stain  with 
a  solution  of  iodine  and  iodide  of  potassium. 

JElastic  fibres  in  the  sputum  are  very  significant ;  they  indicate 
lung-destruction.  They  may  be  found  as  a  bundle  of  fibres,  or  in  the 
shape  of  the  alveolar  lung  structure.  In  the  latter  instance  they  are 
even  a  more  valuable  sign  than  in  the  former.  Elastic  fibres  are  met 
with  most  frequently  in  tubercular  lung-destruction,  but  they  also 
occur  in  abscess  and  in  gangrene  of  the  lung,  in  cavities  from  bron- 
chitis, and,  according  to  Jaksch,  in  pneumonia,  even  where  there  is  no 

^  Stadelmann,  Zeitschrift  fiir  klinische  Medicin,  xvi.,  1889. 


296 


MEDICAL  DIAGNOSIS. 


abscess.  The  most  certain  way  of  finding  the  elastic  fibres  is  to 
liquefy  the  sputum  by  means  of  caustic  soda,  or  to  boil  it  in  a  solution 
of  caustic  soda  or  potassa ;  the  particles  that  fall  to  the  bottom  of  the 
vessel  can  be  readily  removed  and  placed  under  the  microscope. 


Fig.  27. 


Elastic  fibres  of  pulmonary  tissue,  after  treat, 
ment  with  caustic  soda. 


A  spiral  magnified. 


Spirals  are  structures  also  possessing  considerable  significance. 
They  have  been  studied  especially  by  Curschmann,  who  traced  them 
to  an  exudative  inflammation  of  the  bronchioles.  They  are  most 
common  in  asthma,  and  bear  a  close  relation  to  the  Charcot-Leyden 
crystals  which  are  often  embedded  among  the  coils.  They  have  also 
been  found  in  pneumonia.  They  consist  chiefly  of  a  substance  allied 
to  mucin,  and  are  large  enough  to  be  detected  in  the  sputum  with  the 
unassisted  eye,  though  their  peculiar  structure  and  the  central  thread 
are  recognized  clearly  only  with  the  microscope. 

Fibrinous  coagula  are  found  in  the  sputum  of  pneumonia,  of  diph- 
theria that  has  extended  into  the  lung,  but  especially  in  plastic  bron- 
chitis, where  they  furnish  a  very  valuable  diagnostic  sign.  They  are 
moulds  of  the  ramifications  of  the  finest  bronchial  tubes,  whitish  in 
color,  of  arborescent  appearance,  and  consisting  of  fibrin.  They  are 
small  in  pneumonia,  and  do  not  generally  occur  in  any  number ;  should 
they  be  numerous  the  gravity  of  the  case  is  greatly  increased.  They 
can  be  seen  with  the  naked  eye,  or  studied  with  a  low  magnifying 
power.  In  the  description  of  plastic  bronchitis  a  fibrinous  mould  is 
depicted. 

Different  crystals  can  be  discriminated  only  with  the  microscope. 
We  find  cholesterin  crystals  in  the  sputum  of  tuberculosis  and  in 
abscess  of  the  lung ;  the  long,  thin  needles  of  margaric  acid  more 


DISEASES  OF  THE  LUNGS.  297 

especially  in  pulmonary  gangrene  and  in  putrid  bronchitis.*  In  the 
latter  disease  and  in  empyema  breaking  into  the  lung  there  have  been 
also  noticed  by  Leyden  tyrosin  crystals.  Crystals  of  hsematoidin  follow 
a  hemorrhage  retained  for  a  time  in  the  bronchial  tube.  If  the  blood- 
crystals  be  conjoined  to  cells,  they  indi- 
cate, according  to  Jaksch,  a  previous  ^^^-  ^^^ 
hemorrhage  ;  if  any  large  number  of  them 
exist  free,  they  point  to  a  rupture  of  an  ab- 
scess from  neighboring  parts  into  the  lung 
structure.  Uric  acid  crystals  are  encoun- 
tered in  the  expectoration  of  gouty  patients. 
The  colorless,  sharply  pointed,  octahedral 
or  rhomboidal  crystals  described  by  Leyden 
and  Charcot,  and  named  after  them,  occur 
in  various  conditions,  as  in  acute  bronchitis  ; 

T      .    i       1 .       1    ,         ,  11  Charcot-Leyden  crystals. 

m   the   blood,  mtestmal  tracts,  and  bone- 

marrov^  of  leukaemia ;  but  particularly  in  asthma.  There  they  seem 
to  have  a  direct  connection  w^ith  the  attack.  They  are  found  in  the 
sputum  as  little,  round,  yellowish  bodies,  but  require  a  microscope  for 
satisfactory  study.  They  are  soluble  in  warm  water,  in  ammonia,  in 
acetic  acid,  and  in  the  mineral  acids,  and  are  supposed  to  be  phosphate 
of  ethylenimine. 

Sputum  very  frequently  coniains  parasites.  In  it  may  be  found 
the  scolices  and  free  booklets  of  echinococcus,  the  actinomycosis 
fungus,  the  amoeba  coli,  and  others.  Sputum  full  of  amoebse  is  thin 
and  oily.  They  generally  get  into  the  lung  from  hepatic  abscess  fol- 
lowing amoebic  dysentery.  But  the  parasites  of  most  consequence 
are  the  vegetable  parasites,  especially  the  bacilli  and  the  cocci.  Now, 
there  are  many  bacilli  and  cocci  that  are  not  linked  to  any  special 
morbid  condition.  But  these  have  no  particular  diagnostic  value ; 
the  pathogenic  organisms  are  of  the  greatest  importance,  and  most 
important  is  the  tubercle  bacillus,  which  is  revealed  by  its  significant 
action  towards  certain  stains,  an  action  that  it  shares  only  with  the 
bacillus  of  leprosy.  If  the  bacillus  be  exposed  to  an  aniline  dye  dis- 
solved in  an  alkali,  unlike  other  pathogenic  and  non-pathogenic  minute 
organisms,  it  retains  the  color  on  the  subsequent  addition  of  decolor- 
izing reagents,  such  as  acids  and  alcohol.  There  are  many  different 
tests  based  on  this  principle.  The  one  of  Koch,  as  modified  by 
Ehrlich,  is  still,  I  think,  the  favorite ;  though  the  Ehrlich-Weigert 
method  is  also  much  employed.  The  Koch-Ehrlich  method  is  as 
follows :  A  small  drop  of  sputum  is  spread  very  thinly  over  the  sur- 
face of  a  cover-glass,  a  second  cover-glass  is  laid  upon  this,  and  the 

19 


298  MEDICAL  DIAGNOSIS. 

two  are  pressed  together  and  then  separated  by  shding  one  over  the 
other.  The  thin  layer  on  the  surface  of  the  cover-glass  we  select  to 
test  is  dried  by  holding  it  over  a  gas  or  an  alcohol  flame,  the  side  of 
the  specimen  being  up.  The  dry  sputum  is  now  stained  by  letting 
the  cover-glass  lie  for  twenty-four  hours  at  ordinary  temperature  in  a 
saturated  solution  of  aniline  oil  in  water,  made  by  adding  the  oil  drop 
by  drop  to  distilled  water  in  a  test-tube  until  the  mixture  becomes  tur- 
bid, when  it  is  filtered ;  a  few  drops  of  a  saturated  alcoholic  solution 
of  fuchstne,  of  gentian  violet,  or  of  methyl  violet,  are  then  added. 
At  the  end  of  this  time  all  the  component  parts  are  stained,  including 
the  bacilli.  The  cover-glass  is  now  lifted  and  immersed  for  a  few 
seconds  in  a  mixture  of  one  part  of  nitric  acid  to  three  parts  of 
water,  until  the  preparation,  previously  red,  becomes  yellowish-green. 
The  preparation  is  then  placed  in  alcohol  of  seventy  per  cent,  until 
no  more  color  is  given  off;  the  color  disappears,  except  that  of  the 
tubercle  bacilli,  which  are  red.  We  can  then  counterstain  the  other 
parts  blue  by  immersing  the  cover-glass  for  a  few  minutes  in  a  two 
per  cent,  watery  solution  of  methyl-blue  or  of  malachite  green,  unless 
gentian  or  methyl-violet  has  been  employed,  when  Bismarck  brown 
must  be  used  for  the  background.  The  cover-glass  is  then  washed 
in  absolute  alcohol,  dried,  and  the  preparation  mounted  in  oil  of 
cloves  or  in  Canada  balsam. 

There  have  been  many  other  processes  proposed,  among  which 
those  of  Ziehl-Neelsen  and  of  Gabbett,  in  which  carbolic  fuchsine 
instead  of  aniline  water  fuchsine  is  employed,  are  much  used.  The 
latter  is  excellent  for  rapid  staining.^  The  cover-slip  is  kept  for  from 
two  to  five  minutes  in  a  cold  carbolic  fuchsine  solution,  and  then 
counterstained  with  a  methylene-blue  sulphuric  acid  solution,  two 
grammes  of  methylene-blue  to  one  hundred  grammes  of  a  twenty-five 
per  cent,  solution  of  sulphuric  acid.  The  preparation  is  then  rinsed 
off  in  water ;  the  tubercle  bacilli  show  the  marked  red  stain. 

As  seen  when  stained,  tubercle  bacilli  are  fine  rods,  absolutely 
motionless,  of  the  diameter  of  a  human  blood-corpuscle,  and  forming 
spores  of  oval  outline.  Their  presence  in  any  number  is  proof  of  the 
existence  of  tuberculosis ;  when  but  few  are  found  it  is  a  cjuestion 
whether  they  may  not  have  accidentally  got  into  the  air-passages. 

Another  valuable  micro-organism  in  the  sputum  is  the  pneumo- 
eoccus,  especially  the  one  described  by  Fraenkel  as  characteristic  of 

^  See,  for  clear  descriptions  of  the  different  processes,  Schenk's  Manual  of 
Bacteriology,  translation,  London  ;  and  Abbott's  Bacteriology,  4th  edition,  Phila- 
delphia, 1899. 


DISEASES  OF  THE  LUNGS.  299 

pneumonia ;  it  has,  however,  also  been  detected  in  the  saliva,  in 
abscesses,  in  meningitis,  and  in  empyema.  Two  cocci  generally  are 
found  together.  It  is  depicted  in  discussing  pneumonia.  Let  us  here 
examine  only  the  process  by  which  it  is  best  discerned,  which,  more- 
over, is  a  most  valuable  one  in  the  discrimination  of  many  micro- 
organisms, the  process  of  Gram. 

Gram's  decolorizing  method  makes  use  of  an  aqueous  solution  of 
iodine  and  iodide  of  potassium :  one  part  of  iodine,  two  parts  of  iodide 
of  potassium,  and  two  hundred  and  fifty  parts  of  water.  The  prepa- 
ration is  previously  stained  in  aniline  water  solution  of  gentian  violet, 
made  in  the  usual  way  by  shaking  up  in  a  test-tube  filled  with  water 
one  to  two  cubic  centimetres  of  aniline  until  an  emulsion  is  formed, 
which  is  filtered,  and  to  which  enough  of  a  concentrated  solution  of 
gentian  violet  has  been  added  to  render  the  liquid  of  a  dark  color. 

FiCx.  30. 


Tubercle  bacilli. 

The  iodine  solution  is  then  washed  out  of  the  tissues  ;  the  bacilli  or 
cocci  are  easily  isolated  by  the  stain.  The  prepared  "section  or  cover- 
glass  should  be  slowly,  but  completely,  warmed  in  the  aniline  solution 
of  the  gentian  violet,  either  on  the  water-bath  or  over  the  flame,  then 
laid  from  one  to  two  minutes  in  the  aniline  water  solution  of  gentian 
violet,  and  subsequently  placed  in  absolute  alcohol  until  the  color  is 
discharged.  The  bacteria  show  the  stain  of  gentian  violet ;  the  tissue 
may  be  double-stained  red  with  picrocarmine  or  other  dyes. 

This  method  of  Gram  is  of  the  greatest  value  in  distinguishing 
micro-organisms.  For  instance,  it  separates  the  pneumococcus  of 
Friedlaender,  which  does  not  stain  with  it ;  and  the  bacilli  of  cholera, 
of  typhoid  fever,  and  of  glanders  do  not  retain  the  stain. 

Hseraoptysis. — Sputa  are    streaked   with  blood    in    bronchitis, 


300  MEDICAL  DIAGNOSIS. 

intimately  admixed  with  blood  in  pneumonia ;  but  it  is  only  when  a 
certain  quantity  of  pure  blood  is  expectorated  that  the  complaint  is 
regarded  as  haemoptysis,  or  hemorrhage  from  the  lungs.  Now,  a  pul- 
monary hemorrhage  may  be  an  idiopathic  affection  ;  but  it  is  not  often 
so.  It  is  mostly  symptomatic  of  a  grave  disease  of  the  lungs  or  of  the 
heart.  It  is  at  times  a  discharge  that  takes  the  place  of  a  suppressed 
flow  of  blood  from  another  part  of  the  body,  as  in  vicarious  menstrua- 
tion. Among  diseases  of  the  heart,  mitral  disease  is  most  generally 
connected  with  haemoptysis  ;  among  diseases  of  the  lungs,  tubercu- 
losis. But  it  may  also  occur  in  gangrene,  in  bronchial  dilatation,  in 
abscess,  and  in  the  early  stages  of  pneumonia.  We  also  meet  with  it 
in  congestion  of  the  larynx,  in  purpura,  in  typhoid  and  typhus  fevers, 
and  in  arthritic  subjects. 

When  called  to  a  person  who  has  been  spitting  blood,  we  have 
first  to  solve  the  question.  Where  does  the  blood  come  from?  It 
may  issue  from  the  nose  or  mouth  ;  from  the  trachea  ;  from  the  oesoph- 
agus or  stomach ;  it  may  stream  from  an  aneurism  which  has  burst 
into  the  air-passages  ;  or  it  may  be  that  the  lung  is  bleeding. 

When  in  epistaxis  the  blood,  instead  of  flowing  out  of  the  nostrils, 
flows  backward,  it  is  coughed  up.  But  on  the  patient  inclining 
forward,  it  will  issue  from  the  nose.  The  color  of  the  blood  is  not 
florid ;  and  it  can  be  seen  trickling  down  the  pharynx.  Inspection  is 
of  equal  service  when  the  blood  comes  from  any  part  of  the  oral 
cavity ;  especially  if  it  proceed  from  the  gums.  Their  swollen  state, 
their  spongy  appearance,  and  the  readiness  with  which  they  bleed 
when  pressed,  point  out  at  once  the  source  of  the  hemorrhage. 

Loss  of  blood  from  the  larynx  and  the  trachea,  or  from  the 
oesophagus,  is  exceedingly  rare ;  and  when  it  does  occur,  it  is  depen- 
dent upon  some  local  lesion,  such  as  an  ulcer,  or  the  presence  of 
some  foreign  substance  that  has  been  swallowed.  By  attention  to 
the  history,  then,  we  can  recognize  the  cause  and  the  seat  of  the  hem- 
orrhage. The  blood  itself  furnishes  no  certain  mark  of  distinction. 
Occasionally  the  hemorrhage  takes  place  into  the  interior  of  the 
larynx,  and  only  a  very  small  quantity  of  blood  is  expectorated. 
Cases  of  hemorrhagic  laryngitis  are  usually  connected  with  catarrhal 
inflammation  of  the  windpipe,  with  or  without  ulceration ;  they  are 
accompanied  by  severe  dyspnoea,  and  with  the  laryngeal  mirror  the 
blood  can  be  seen  trickling  down  the  windpipe. 

When  blood  is  vomited  from  the  stomach,  it  is  preceded  by  a  feel- 
ing of  weight  and  uneasiness  in  the  epigastric  region,  and  sometimes 
by  decided  nausea.  The  ejected  matter  consists  of  a  dark  grumous 
blood,  thus   altered   by  the  gastric  juice,  and  is  often  mixed  with 


DISEASES  OF  THE  LUNGS.  301" 

broken-down  food.  Its  dark  color  is  invariable',  except  where  an 
artery  has  been  laid  bare  by  an  ulcer,  in  which  case  a  sudden  dis- 
charge of  florid  blood  takes  place.  There  is  not  commonly  more 
than  one  act  of  vomiting ;  the  blood  which  remains  in  the  stomach 
passes  into  the  intestines,  and  goes  off  with  the  stools.  Hsematemesis 
is  attended  with  tenderness  at  the  epigastrium.  It  is  usually  symp- 
tomatic of  an  organic  affection  of  the  stomach,  liver,  intestine,  or 
spleen  ;  it  may,  however,  depend  upon  the  swallowing  of  irritating 
poisons ;  or  happen  in  fev&rs  or  in  scurvy,  or  as  a  substitute  for 
suppressed  discharges. 

The  blood  which  gushes  out  of  the  mouth  when  an  aneurism 
opens  into  the  air-passages  is  red  and  arterial.  It  spurts  out  in  jets, 
and  the  patient  rarely  long  survives  the  hemorrhage.  Should  this  not 
prove  quickly  fatal,  we  are  seldom  at  a  loss  to  determine  the  cause  of 
the  bleeding ;  for  we  find  the  physical  signs  of  the  aneurismal  tumor. 

But  when  the  blood  comes  from  the  lungs,  it  is  of  a  character, 
and  is  connected  with  symptoms,  totally  different  from  any  of  those 
just  mentioned.  The  bleeding  is  preceded  by  a  sense  of  weight  and 
of  uneasiness  in  the  chest.  The  patient  perceives  a  saltish  taste  in 
the  mouth  and  a  tickling  sensation  in  the  larynx,  when  suddenly  the 
mouth  fills  with  blood,  or,  after  a  slight  cough,  he  expectorates  a 
quantity  of  light-red  and  frothy  blood.  His  anxiety  becomes  great ; 
the  skin  is  covered  with  a  cold  sweat ;  the  pulse  is  quick  and  bounds 
under  the  finger.  He  spits  up  more  blood,  and  this  continues  to 
come  up  at  varying  intervals  and  in  changing  quantities  all  day,  or  for 
several  days,  or  even  for  a  much  longer  period.  It  is  at  first  pure 
blood,  or  mixed  with  the  sputum  ;  is  red  and  not  coagulated,  and 
frothy,  except  when  the  hemorrhage  is  very  profuse.  But  after  one 
or  two  bleedings,  the  matter  which  is  coughed  up  contains  dark  clots, 
being  the  blood  which  has  been  retained  somewhere  in  the  air- 
passages  since  the  previous  attack.  The  blood  is  never,  at  the  onset 
of  the  hemorrhage,  dark  and  grumous  ;  yet  in  rare  cases  it  has  more 
of  a  venous  than  of  an  arterial  hue.  The  amount  which  is  brought 
up  at  one  bleeding  ranges  from  one  to  two  drachms  to  as  many  pints ; 
but  the  quantity  that  comes  out  of  the  mouth  is  by  no  means  an 
index  of  the  quantity  extravasated.  The  blood  may  be  effused  into 
the  pulmonary  structure,  and  but  little  be  expelled. 

After  the  description  above  given,  it  is  unnecessary  to  point  out 
the  marks  of  discrimination  between  blood  ejected  from  the  lungs 
and  blood  from  other  parts.  The  symptoms  are  different ;  the  blood 
itself  is  different.  And  listening  to  the  chest  detects  bubbling  sounds 
in  the  air-tubes  ;  still,  to  find  these  is  not  requisite  for  the  diagnosis 


'302  MEDICAL  DIAGNOSIS. 

of  pulmonary  hemorrhage,  and  indeed,  while  the  bleeding  is  going 
on,  the  i^atient's  welfare  forbids  an  extended  thoracic  examination. 
The  bleeding  is  mostly  owing  to  an  affection  of  the  heart  or  the 
Imigs,  and  is  exceedingly  prone  to  be  repeated. 

Yet  the  lungs  may  bleed  frequently  without  there  beiQg  an  organic 
lesion  within  the  chest  to  account  for  the  hemorrhage.  I  had,  some 
years  ago,  a  patient  under  my  care  who  had  been  spitting  blood  daily 
for  five  years.  Although  enfeebled  by  the  loss  of  blood,  his  general 
health  remained  good.  His  lungs  and  heart  appeared  to  be  sound. 
Another  patient  had  pulmonary  hemorrhages  at  varying  intervals  for 
eighteen  months.  He  finally  died  of  exhaustion  ;  but  he  never  pre- 
sented any  physical  signs  of  thoracic  disease.  In  another  case  that  I 
watched  for  years,  the  repeated  hemorrhages  were  found,  at  the 
autopsy,  to  be  unconnected  with  disease  of  the  lungs. 

In  these  instances  the  hemorrhages  recurred  often.  But  we  meet 
with'  robust  persons  in  whom  the  loss  of  blood  follows  active  exercise 
or  exertion,  and  is  not  apt  to  be  protracted  or  to  be  repeated.  In  such 
cases,  of  which  I  have  seen  a  number  in  soldiers  sent  to  hospitals 
after  the  fatigue  of  a  long  march  or  the  excitement  of  a  battle,  simple 
congestion  of  the  lungs  is  probably  the  cause  of  the  disorder. 

Except  under  the  circumstances  mentioned,  haemoptysis  is  a  grave 
symptom.  It  is  not  dangerous  as  regards  its  immediate  termination, 
but  dangerous  because  it  is,  usually,  the  indication  of  a  serious  malady. 
Few  die  as  the  direct  consequence  of  the  hemorrhage,  but  many  die 
of  the  disorder  of  which  the  hemorrhage  is  the  consequence. 

Diseases  in  which  Clearness  on  Percussion  is  met  with  and 
constitutes  a  Valuable  Sign, 

Some  of  these  ailments  are  acute,  others  chronic ;  and  nearly  all 
have  as  their  prominent  symptom  a  cough,  and  are  affections,  or 
follow  affections,  of  the  bronchial  tubes. 

Acute  Bronchitis. — This  is  an  acute  catarrhal  inflammation  of 
the  bronchial  mucous  membrane,  which  occurs  idiopathically,  or 
happens  as  a  secondary  complaint  in  the  course  of  fevers,  of  rheuma- 
tism, and  of  cardiac  disorders. 

Bronchitis  varies  considerably  according  to  the  .  tubes  involved. 
The  symptoms  of  acute  bronchitis  of  the  large  and  middle-sized  tubes  are, 
a  sensation  of  tickling  in  the  throat,  soreness  or  pain  behind  the 
sternum  and  along  the  lower  ribs,  a  slight  oppression  in  breathing, 
and  a  paroxysmal  cough.  Let  us  add  to  these  pain  in  the  limbs, 
coryza,  and  a  fever  of  moderate  intensity,  rarely  reaching  103°  F., 
and  we  have  the  main  phenomena  met  with  during  the  onset  and 


DISEASES  OF  THE  LUNGS.  303 

at  the  height  of  an  attack  of  ordmary  acute  bronchitis.  The  fits 
of  coughing  in  tlie  eariier  stages  are  followed  by  a  clear,  frothy  ex- 
pectoration, which,  as  the  cough  becomes  looser  and  less  fatiguing, 
changes  from  an  almost  transparent  fluid  to  a  yellowish  or  greenish 
sputum.  This  may  be  uniform  or  streaked  with  blood  ;  it  may  be  small 
in  amount,  or  in  considerable  quantity ;  and  it  consists  chiefly  of  pus 
cells  and  of  large,  round,  alveolar  cells  with  some  blood-corpuscles. 
The  fever  soon  leaves  ;  but  long  after  it  has  ceased,  the  patient  still  has 
a  cough  and  expectoration,  both  of  which  only  gradually  disappear. 

The  physical  signs  may  be  inferred  from  the  lesions.  As  there  is 
no  condensation  of  pulmonary  tissue,  there  is  no  dulness  on  percus- 
sion, the  thickening  and  injection  of  the  bronchial  mucous  membrane 
not  being  sufficient  to  modify  materially  the  normal  resonance.  But 
these  conditions  must  alter  the  respiratory  murmur.  They  bring  out 
more  of  the  bronchial  element  of  sound,  hence  more  expiration  with 
the  coarser  inspiration, — in  other  words,  a  harsh  respiration ;  or  the 
swelling  obstructs  the  entrance  of  air  into  the  air-vesicles,  and  enfee- 
bles the  vesicular  murmur.  Again,  new  sounds,  the  rales,  are  pro- 
duced ;  first  dry,  then  moist.  This  succession  of  the  rales  is,  however, 
not  absolute,  and  depends,  to  a  great  degree,  on  the  density  of  the 
fluid  in  the  bronchial  tubes.  Dry  rales,  mixed  with  moist,  may  be 
perceived  even  in  the  later  stages  of  acute  bronchitis,  and  long  after 
the  febrile  signs  have  ceased.  In  fact,  the  tenacity  alone  of  the  exu- 
dation determines  the  nature  of  the  rales,  and  even  somewhat  their 
exact  character ;  for  every  dry  rale  is  not  precisely  like  every  other 
dry  rale,  nor  every  moist  rale  equally  moist.  With  reference  to 
size,  the  sonorous  rales  and  the  large  bubbling  sounds  prevail  when 
the  disorder  attacks  the  larger  tubes.  Sometimes,  when  the  bronchial 
inflammation  is  severe  and  extensive,  Ave  find  a  sound  which  seems  to 
be  neither  a  dry  nor  a  bubbling  rale,  but  rather  a  conapound  of  both, 
— a  dry  sound,  yet  not  continuous,  giving  the  idea  of  being  caused  by 
the  breaking  up  of  fluid.  Or,  there  may  be  a  mixture  of  the  sounds 
of  respiration  with  the  rales,  occasioning  a  peculiar  kind  of  breathing, 
one  in  which  we  can  recognize  neither  a  distinctly  vesicular  nor  a 
distinctly  bronchial  element,  nor  a  well-defined  rale.  All  these  states 
are  dependent  upon  the  amount,  and,  above  all,  upon  the  condition, 
of  the  exudation  in  the  bronchial  tubes.  But  they  indicate  nothing 
beyond  the  fact  that  there  is  an  exudation  present  which  is  very  large 
in  quantity  and  tenacious  in  character.  When  the  sounds  are  of  the 
indeterminate  nature  just  alluded  to,  the  vibrations  produced  in  the 
tubes  are  apt  to  be  transmitted  to  the  parietes  of  the  chest,  occasion- 
ing with  each  respiration  a  marked  fremitus. 


304  MEDICAL  DIAGNOSIS. 

The  diagnosis,  then,  of  acute  bronchitis  is  determined  by  the 
cough,  the  fever,  the  expectoration,  and  the  signs  of  clearness  on  per- 
cussion, diffused  rales,  or  harsh  respiration.  From  all  those  diseases 
of  the  lung  which  result  in  the  consolidation  of  the  pulmonary  tissue, 
such  as  pneumonia  and  tuberculosis^  we  distinguish  bronchitis  by  the 
absence  of  dulness  on  percussion.  Some  cases  of  acute  tuberculosis 
on  account  of  the  sudden  invasion  of  the  malady  and  the  general 
diffusion  of  the  physical  signs,  are  liable  to  be  mistaken  for  acute 
bronchitis  ;  but  the  different  progress  of  the  disorder  usually  clears 
up  all  doubt.  Error  in  diagnosis  is  more  likely  to  arise  from  the 
habit,  when  the  signs  of  bronchitis  have  been  made  out,  of  not  look- 
ing farther ;  forgetting  that  it  is  far  from  always  idiopathic,  and  par- 
ticularly its  frequent  association  with  the  eruptive  fevers,  such  as 
measles  and  smallpox,  with  typhoid  fever,  with  influenza,  or  its 
occurrence  in  rheumatism  and  in  malaria. 

Capillary  Bronchitis. — This  is  a  disease  of  the  aged  and  of  young 
children.  It  begins  with  an  acute  inflammation  of  the  larger  bronchi ; 
or  the  disorder  may  from  the  onset  affect  the  smaller  tubes.  In  either 
case,  signs  of  obstructed  circulation  soon  manifest  themselves ;  there 
is  lividity  of  the  lips*  and  cheeks,  with  hurried  breathing,  a  rapid  pulse, 
an  anxious  countenance,  great  restlessness,  moderate  fever  tempera- 
ture, and  a  cough,  followed  by  viscid  expectoration.  As  the  malady 
advances,  the  color  of  the  skin  and  the  mucous  membranes  shows 
more  and  more  the  want  of  properly  aerated  blood ;  the  sputa  cease 
with  the  failing  strength ;  and  in  old  persons  delirium  and  coma,  in 
young  children  convulsions,  mark  the  closing  struggle. 

The  physical  signs  are  those  of  ordinary  bronchitis,  but  modified 
by  the  seat  of  the  malady.  High-pitched  whistling  sounds,  accom- 
panied or  superseded  by  very  fine  moist  rales,  denote  the  smaller  size 
of  the  tubes  involved.  ,  The  resonance  on  percussion  is  clear,  or  very 
slightly  different  from  that  of  health.  When  materially  duller,  it  indi- 
cates that  the  pulmonary  tissue  itself  shares  in  the  inflammation,  or 
that  it  has  been  exhausted  of  its  air  and  has  collapsed. 

The  parts  of  the  lung  which  the  physical  signs  prove  to  bear  the 
brunt  of  the  disease  are  the  lower  lobes.  In  the  upper  there  may  be 
large  rales  and  some  fine  ones ;  but  it  is  low  down  and  at  the  poste- 
rior portion  of  the  chest  that  the  fine  sounds  are  most  abundant.  Yet 
when  the  inflammation  is  extensive,  and  the  accumulation  of  secre- 
tions and  morbid  products  great,  quantities  of  small  rales  are  heard 
at  every  part  of  the  chest. 

Like  the  more  usual  kind  of  acute  bronchial  inflammation,  capil- 
lary bronchitis  is  liable  to  be  mistaken  for  acute  lobar  pneumonia  and 


DISEASES  OF  THE  LUNGS.  305 

for  phthisis.  And  in  the  majority  of  cases  the  same  rules  serve  for  its 
discrimination ;  the  absence  of  percussion  dulness  and  the  diffusion 
of  the  morbid  sounds  are  here  again  of  the  utmost  value.  The 
rapidity  of  the  attack  and  the  signs  of  suffocation  might  mislead  into 
the  supposition  of  the  existence  of  oedema  of  the  glottis,  of  laryngitis, 
or  of  croup ;  errors  in  diagnosis  which  the  detection  of  fme  chest 
rales  will  prevent. 

Capillary  bronchitis  which  really  merits  the  name  is  a  very  rare 
disease,  though  I  believe  it  to  exist.  What  is  called  capillary  bron- 
chitis is  for  the  most  part  catarrhal  pneumonia  or  broncho-pneumonia 
one  of  the  most  common,  as  it  is  one  of  the  most  fatal,  of  the  diseases 
of  childhood.  Like  capillary  bronchitis,  the  disease  affects  both  lungs. 
It  is  commonly  observed  in  connection  with  measles,  whooping-cough, 
influenza,  or  diphtheria ;  it  is  especially  seen  in  children  previously  in 
impaired  health,  or  scrofulous,  or  rhachitic.  It  is  apt  to  be  attended 
by  cerebral  symptoms, — indeed,  it  may  set  in  with  these, — by  rapid 
breathing  and  paroxysms  of  dyspnoea,  and  by  high  and  irregular  fever, 
ranging  between  102°  and  105°.  As  the  inflammation  is  hmited  to 
the  lobules,  it  yields  but  imperfect  signs  of  consolidation.  The  bron-. 
chial  breathing  is  rarely  very  marked ;  crepitant  rale  is  not  usually 
perceived,  or  can  scarcely  be  distinguished  from  the  small  bubbling 
sounds  of  fine  bronchitis ;  and,  from  the  usual  association  with  in- 
flammation of  the  fine  bronchial  tubes,  it  is  in  individual  cases  often 
extremely  difficult  to  say  whether  portions  of  the  lung-tissue  are  con- 
solidated. Theoretically,  broncho-pneumonia  may  be  distinguished 
from  capillary  bronchitis  by  the  dulness  on  percussion ;  practically, 
this  aids  but  little.  Dulness  on  percussion  is  in  children  difficult  to 
elicit ;  and,  again,  a  dulness  may  be  temporarily  produced  in  capillary 
bronchitis  by  coUapse  of  the  pulmonary  tissue. 

Broncho-pneumonia  may  or  may  not  be  preceded  by  bronchitis  of 
the  fine  tubes.  We  may  suspect  that  the  inflammation  has  affected 
the  lobules,  if  the  breathing  be  very  rapid,  the  fever  severe,  and  the 
temperature,  which  is  rarely  above  102°  in  the  preceding  bronchitis 
of  the  finer  tubes,  rise  suddenly  by  several  degrees;  if  the  cough 
lessen  as  the  pneumonia  develops  ;  if  laryngeal  symptoms  arise ;  and 
if,  in  addition  to  rales,  not  very  diffused,  spots  of  dulness,  which  do 
not  change  their  seat,  and  do  not  disappear  under  respiratory  percus- 
sion, be  discerned,  and  plastic  pleurisy  appear  as  a  complication.  On 
the  other  hand,  when  there  are  early  and  marked  signs  of  deficient 
aeration  of  blood ;  when  the  child  seems  to  suffocate  from  want  of 
power  to  expectorate  ;  when  a  multitude  of  fine  dry  and  moist  sounds 
are  heard  at  every  part  of  the  chest,  and  little  or  no  corresponding 


306  MEDICAL   DIAGNOSIS. 

impairment  of  resonance  on  percussion  is  detected, — we  know  that 
the  capillary  bronchi  are  extensively  filled  with  pus  and  morbid  se- 
cretions, and  that  true  suffocative  catarrh  is  threatening  life.  Capillary 
bronchitis  is  a  rapid  disease  ;  catarrhal  pneumonia  runs  a  much  slower 
course,  lasting  perhaps  weeks,  and  showing  a  temperature  record  that 
is  marked  by  great  alternations  between  morning  and  evening. 

Chronic  Bronchitis. — The  symptoms  and  signs  of  chronic  bron- 
chitis are  not  very  different  from  those  of  the  ordinary  form  of  acute 
bronchitis.  The  duration  of  the  complaint  and  the  absence  of  fever, 
except  during  marked  subacute  or  acute  exacerbations,  are  the  chief 
distinguishing  elements.  Yet  the  cough,  although  on  the  whole 
chronic,  is  far  from  being  constant.  It  may  disappear  almost  alto- 
gether, and  then  reappear  with  more  than  its  previous  severity ;  and 
this  state  of  things  may  go  on  for  years,  undue  exposure  and  change 
of  season  aggravating  the  disorder. 

The  sputa  vary,  even  more  than  in  acute  bronchitis,  in  tenacity 
and  quantity.  There  may  be  merely  a  small  quantity^  of  yellowish 
'matter  expectorated  in  the  morning,  or  an  almost  continued  flow 
from  the  bronchial  tubes, — bronchorrhoea.  The  physical  signs  differ 
accordingly.  A  harsh  or  feeble  respiration,  and  few  or  many,  either 
dry  or  moist,  rales,  are  present,  in  conformity  with  the  state  of  the 
bronchial  mucous  membrane  and  of  the  secretions.  The  sound  on 
percussion  is  clear,  and  this,  with  the  diffusion  of  the  signs  discerned 
on  auscultation,  is  of  great  importance.  Excessive  secretions  some- 
what impair  the  pulmonary  resonance,  but  only  temporarily  ;  for  with 
the  shifting  secretions  shifts  the  very  slight  dulness. 

One  of  the  most  important  points  in  the  diagnosis  of  chronic 
bronchitis  is  to  attend  to  the  manner  in  which  it  arises.  It  may 
follow  a  seizure  of  acute  bronchitis,  or  be  the  result  of  recurring 
attacks  of  subacute  character ;  it  may  appear  as  a  primary  affection, 
or  it  may  follow  the  exanthemata ;  or,  again,  it  may  complicate  some 
previously  existing  disorder,  as  Bright's  disease,  rheumatism,  lithaemia, 
gout,  psoriasis,  or  eczema,  and  be  directly  traceable  to  the  constitu- 
tional taints  of  these  maladies  ;  and  its  symptoms  will  vary  and  be 
influenced  by  those  of  the  general  malady  to  which  it  is  subordi- 
nate. 

In  the  ordinary  idiopathic  malady  the  general  health,  as  a  rule, 
suffers  but  little.  In  some,  instances,  however,  emaciation  takes  place, 
a,nd  the  disease  simulates  phthisis.  This  is  particularly  the  case  in 
the  bronchial  affections  among  knife-grinders  and  coal-miners,  also  in 
those  of  granite-masons,  of  sandpaper-makers,  of  flax-dressers,  and 
of  potters.     The  resemblance  becomes  still  greater  when  superadded 


DISEASES  OF  THE  LUNGS.  307 

bronchial  dilatation  and  fibroid  induration  of  the  lung  produce  physical 
signs  like  those  of  pulmonary  consumption. 

A  chronic  catarrhal  ■inflammation  of  the  mucous  membrane  of  the 
nose  may  be  mistaken  for  chronic  bronchitis,  with  which,  indeed,  it 
may  coexist.  But  when  occurring  uncombined,  there  are  no  rales  in 
the  chest  or  altered  breathing-sounds  indicative  of  disorder  there, 
though  there  may  be  a  cough,  from  the  throat  being  also  affected. 
The  secretion,  too,  from  the  nose  is  very  copious  and  of  muco-puru- 
lent  character,  the  upper  part  of  the  nose  looks  somewhat  flattened, 
and  the  sense  of  smell  is  impaired, — not  one  of  which  signs  is  met 
with  in  chronic  bronchitis,  A  minute  inspection  of  the  nasal  mem- 
brane or  a  rhinoscopic  examination  is  of  most  value. 

It  seems  almost  unnecessary  to  speak  of  the  differential  diagnosis 
between  chronic  bronchitis  and  rose  cold  and  hay  asthma.  The  coex- 
istence of  marked  signs  of  irritation  of  the  eyes,  the  nose,  and  the 
throat ;  the  appearance  of  the  distressing  affections  at  a  particular 
period  of  the  year ;  the  fixed  time  in  which  they  run  their  course  ; 
their  occurrence  in  those  of  neurotic  constitution  and  having  an  irri- 
table nasal  mucous  membrane  ;  the  almost  instant  relief  on  leaving 
the  regions  where  the  attack  has  been  brought  on  and  on  reaching 
favorable  localities  ;  the  depression  of  the  nervous  system ;  and,  on 
the  other  hand,  the  less  decided  signs  of  bronchial  affection, — clearly 
distinguish  the  maladies. 

We  meet  occasionally  with  a  form  of  bronchitis  in  which  the 
expectorated  matter  is  solid.  This  plastic  bronchitis  presents  all  the 
usual  signs  and  symptoms  of  bronchial  inflammation.  It  may  be 
chronic  or  it  may  be  acute.  It  is  most  frequently  chronic,  with  occa- 
sional acute  or  subacute  exacerbation.  The  disease  extends  in  this 
way  over  weeks,  months,  or  even  years,  and  is  apt  to  end  in  complete 
recovery.  But  in  its  acute  form  it  is  a  complaint  of  great  danger  and 
accompanied  by  much  dyspnoea,  and  has  led  to  death  by  suffocation.^ 
Males,  as  we  find  by  looking  at  the  cases  which  Peacock  ^  has  col- 
lected, are  more  often  attacked  than  females.  The  same  carefully 
collated  observations  show  that  the  disorder  affects  more  commonly 
the  upper  than  the  lower  part  of  the  lungs.  As  regards  the  physical 
signs.  Fuller,^  who  has  met  with  a  number  of  well-marked  examples 
of  the  complaint,  states  that  tliere  is  weakness  or  entire  absence  of 
breathing  over  the  affected  portions  of  the  lungs,  and  that,  from  at- 

^  Andral,  Clinique  Medicale. 

^Transactions  of  the  Pathological  Society  of  London,  vol.  v. 

'  Diseases  of  the  Chest. 


308 


MEDICAL  DIAGNOSIS. 


Fig.  31. 


Cast  from  a  case  of  plastic  bronchitis. 


tending  collapse,  complete  and  rapidly  developed  dulness  on  percus- 
sion may  ensue.  But  the  only  absolutely  diagnostic  phenomenon  is 
the  peculiar  membranous  material  expectorated.  In  form  this  may 
be  either  in  thin  shreds,  or  moulded  into  an  accurate  cast  of  a  bron- 
chial tube  and  its  ramifications.  The  expectoration  of  the  firm  bodies 
is  sometimes  attended  with  copious  haemoptysis.     The  casts  consist 

of  layers  of  fibrin  in  which  leucocytes 
and  alveolar  epithelium  are  embedded. 
Leyden's  crystals  and  Curschmann's 
spirals  may  be  found.  The  disease 
is  most  apt  to  occur  in  the  spring 
months. 

The  little,  round,  solid  pellets  which 
consumptive  patients,  or  even  some  per- 
sons in  good  health,  cough  up  from  time 
to  time  are  the  result  of  a  plastic  bron- 
chitis on  a  limited  scale ;  but  in  a  cer- 
tain proportion  of  chronic  cases  decided 
plastic  bronchitis  and  tuberculosis  are 
associated.  A  kindred  disease  to  plas- 
tic bronchitis  has  been  described  as  "  bronchiolitis  exudativa."  The 
sputum  is  grayish  and  very  tenacious,  and  full  of  spirals  which  come 
from  the  bronchioles.  Gradually  increasing  dyspnoea  and  attacks  of 
asthma  are  prominent  symptoms.^ 

Another  variety  of  chronic  bronchitis  is  jputrid  bronchitis.  This 
may  happen  in  connection  with  bronchial  dilatation  or  with  chronic 
pneumonia,  or  without  these  conditions  ;  occasionally  it  appears  after 
a  suppurative  pleurisy  which  has  broken  into  the  lung.  There  is  fever 
with  irregular  temperature  ;  at  times  chills  occur.  The  distressing 
cough  is  followed  by  a  copious  half-liquid  sputum,  extremely  offen- 
sive, and  containing  little  yellowish  plugs,  the  so-called  Dittrich  plugs. 
The  peculiar  odor  is  thought  to  be  due  to  a  micro-organism,  espe- 
cially to  a  short,  slightly  curved  bacillus  described  by  Lumnitzer.^ 
Cases  of  putrid  bronchitis  may  be  mistaken  for  gangrene  of  the  lung ; 
but  the  odor  is  different,  and  they  lack  the  physical  signs  of  lung- 
destruction  and  elastic  fibres  in  the  sputum.  We  must,  however, 
bear  in  mind  that  putrid  bronchitis  may  terminate  fatally  by  induced 
pneumonia  or  pulmonary .  gangrene.  Sometimes  it  produces  death 
by  metastatic  abscess  of  the  brain. 


1  Curschinann,  Deutsch.  Arch,  fur  klin.  Med.,  Nov.  1882. 

2  Wien.  Mediz.  Presse,  May,  1888. 


DISEASES  OF  THE  LUNGS.  309 

Emphysema. — A  distention  of  the  air-cells  is  a  frequent  sequel 
of  chronic  bronchitis.  It  may  happen  in  only  one  lung ;  but  the 
air-vesicles  of  both  are  usually  distended.  The  effect  of  this  is 
to  obliterate  some  of  the  capillaries,  and  to  interfere  with  the  flow 
of  blood  through  the  lungs.  From  this  proceed  the  feeling  of  con- 
striction and  the  dyspnoea,  the  anxious  look,  the  bluish  lip,  of  em- 
physematous patients,  and  the  tendency  the  disease  has  to  pro- 
duce dilatation  or  dilated  hypertrophy  of  the  right  side  of  the 
heart. 

Emphysema  is  essentially  a  chronic  malady  ;  but  m  its  course 
subacute  attacks  of  bronchitis  occur  which  much  augment  the  diffi- 
culty of  respiration.  The  embarrassment  in  breathing  is,  indeed,  the 
most  prominent  of  the  symptoms.  It  is  not  so  much  the  difficulty  of 
getting  air  into  the  lung,  as  it  is  of  getting  it  out,  which  annoys  the 
patient.  He  breathes  as  if  he  had  no  object  but  that  of  forcing  the 
air  out  of  the  pulmonary  tissue.  And  this  task  is  often  aggravated 
by  spasmodic  narrowing  of  the  bronchial  tubes  ;  hence  it  is  very 
common  to  meet  with  the  loud  wheezing  of  asthma  in  those  whose 
air-cells  are  permanently  dilated.  In  long-standing  cases  of  the  dis- 
ease the  patient  looks  cachectic,  is  cyanosed,  the  shoulders  are 
rounded,  the  chest  is  barrel-shaped,  and  dropsy  of  the  feet  is  noticed. 
There  may  be  also  a  chronic  cough,  which  may  be  dry  and  occur  in 
paroxysms  of  marked  intensity. 

The  physical  signs  of  emphysema  are  easily  deducible  from  the 
pathological  conditions.  The  distention  of  the  lung-tissue  explains 
the  great  prominence  and  fulness  of  the  chest,  and  the  displacement 
of  the  liver  or  heart.  The  ringing  clearness  on  percussion — at  times 
almost  tympanitic  in  its  character — and  the  increased  resistance  to 
the  finger  have  the  same  cause.  Nor  is  it  difficult  to  understand  how 
the  loss  of  elasticity  in  the  dilated  air-cells  will  give  rise  to  an 
unchanged  note  on  respiratory  percussion,  to  prolonged  expiration, 
and  to  a  feeble  inspiratory  murmur.  If  bronchitis  coexist,  the  signs 
on  auscultation  are  necessarily  somewhat  altered.  The  respiration  is 
harsh,  or  intermixed  with  dry  and  moist  rales.  The  former  espe- 
cially assume  great  prominence,  and  are  heard  as  sonorous,  or  still 
oftener  as  sibilant,  rales,  during  the  prolonged  and  labored  act  of 
expiration.  Occasionally  a  crackling  sound  is  heard  in  emphysema.^ 
When  the  emphysema  is  partial,  all  these  signs  are  limited ;  when  it 
is  more  general,  they  are  diffused. 

If  the  upper  lobe  of  the  right  lung  or  the  lower  lobe  of  the  left, 

^  Gerhardt,  Berlin,  klin.  Wochenschr.,  March  12,  1888. 


310 


MEDICAL  DIAGNOSIS. 


which,  according  to  Louis/  are  the  parts  most  frequently  affected,  be 
emphysematous,  the  visible  local  bulging  might  mislead  into  the  idea 
of  the  prominence  being  due  to  an  aneurismal  tumor,  or  to  the  pres- 
ence of  fluid  in  the  pleural  cavity.  Any  doubt  will,  however,  be  dis- 
pelled by  a  careful  examination  of  the  chest.  The  dulness  over  an 
aneurismal  tumor,  its  pulsation,  and  its  sounds,  are  different  from  the 

Fig.  32. 


»i? 


Appearance  of  the  chest  in  a  patient  suffering  from  a  high  .degree  of  emphysema.  The  heart  is 
displaced.  The  other  pliysical  signs  are  extreme  percussion  clearness ;  a  feeble,  hardly  audible 
inspiration ;  a  very  prolonged  expiration. 

exaggerated  clearness  on  percussion  and  the  changed  respiratory 
murmur  of  an  emphysematous  lung.  Pleuritie  effusions  produce  a 
bulging  at  the  lower  part  of  the  thorax.  But,  although  there  may 
be  a  very  clear,  or  rather  a  tympanitic,  sound  above  the  fluid,  the 
absolute  dulness  over  it  shows  that  the  prominence  of  the  chest  is 
not  caused  by  distended  air-vesicles.  When  the  emphysema  is 
extended  and  general,  displacement  of  the  liver  or  heart  results  ; 
and  this,  taken  in  connection  with  the  dilatation  of  the  chest  and  the 
dyspncEa,  may  cause  the  disease  to  be  mistaken  for  pneumothorax. 
The  differences  are  pointed  out  in  the  discussion  of  this  complaint. 


Memoires  de  la  Societe  Medicale  d' Observation,  tome  i. 


DISEASES  OF  THE  LUNGS.  31 1 

We  shall  only  here  add  that  the  affection  of  the  heart,  the  torpid, 
displaced  liver,  and  the  presence  of  albumin  in  the  urine,  in  emphy- 
sematous patients,  may  call  away  attention  from  the  primary  pulmo- 
nary cause. 

An  effusion  of  air  may  take  place  into  the  areolar  tissue  uniting 
the  lobules.  There  are  no  physical  signs  peculiar  to  this  interlobular 
emphysema ;  they  are  exactly  the  same  as  those  furnished  by  dilata- 
tion of  the  air-cells,  except  that  a  dry  friction-sound  and  a  large,  dry 
crackling,  both  of  which  occur  occasionally  in  vesicular  emphysema, 
are  much  more  common.  Its  suddenness  and  the  external  emphy- 
sema which  follows  are  specially  mdicative  of  the  disease.  The 
latter  is  detected  under  the  jaw,  or  at  the  base  of  the  neck,  and  yields 
a  peculiar  crepitation.  Yet  the  extravasation  of  air  into  the  areolar 
tissue  of  the  neck  is  not  a  constant  attendant.  Besides,  the  possi- 
bility of  a  crepitating  swelling  in  the  neck  being  due  to  a  rupture  of 
the  bronchial  tube  or  of  the  larynx  must  be  borne  in  mind. 

The  rupture  of  the  air-cells  which  gives  rise  to  interlobular  em- 
physema is  brought  about  by  any  severe  effort,  by  violent  coughing, 
by  laughing,  or  by  the  throes  of  parturition.  It  has  also  been  known 
to  happen  in  the  course  of  pneumonia  or  of  pulmonary  hemorrhage, 
and  to  have  caused  sudden  death.  Its  most  frequent  association  is  with 
whooping-cough. 

A  compensatory  emphysema  is  met  with  when  distention  of  the  air- 
cells  takes  place  in  the  unaffected  lung  or  in  an  unaffected  lobe.  It 
generally  occurs  at  the  anterior  margins,  and  is  developed  by  the  high 
tension  in  the  air-vesicles  that  have  to  do  more  duty.  It  is  chiefly 
found  in  extensive  pleural  effusion,  in  pneumothorax,  and  sometimes 
in  pneumonia.     The  physical  signs  are  those  of  ordinary  emphysema. 

In  all  the  disorders  which  have  just  been  treated  of,  the  resonance 
on  percussion  has  been  dwelt  upon  as  a  most  valuable  sign.  Before 
proceeding  to  consider  the  diseases  in  w^hich  dulness  is  encountered, 
a  few  words  may  here  find  their  place  on  a  morbid  condition  in  which 
clearness  rapidly  gives  way  to  dulness,  and  dulness  changes  quickly 
back  into  clearness.  As,  moreover,  the  complaint  to  which  I  allude — 
collapse  of  the  lung — has  a  close  connection  with  bronchitis  and  em- 
physema, its  consideration  is  at  this  time  fitting. 

The  chief  cause  of  collapse  of  the  lung,  or  post-natal  atelectasis, 
is  accumulations  in  the  bronchial  tubes.  No  air  can  enter  the  air- 
vesicles  ;  the  residual  air  in  them  is  gradually  exhausted,  and  the 
disordered  portion  of  lung  is  reduced  to  a  state  as  if  it  had  never 
breathed.     But,  although  in  the  majority  of  instances  this  post-natal 


312  MEDICAL  DIAGNOSIS. 

atelectasis  is  brought  about  by  catarrhal  secretions  in  the  bronchial 
tubes  which  cannot  be  expectorated,  any  want  of  power  to  fill  the 
cells  of  the  lung  with  air  may  lead  to  their  collapsing.  In  some  of 
the  typhoid  forms  of  acute  and  chronic  diseases,  in  the  pulmonary 
congestions  of  the  aged  and  enfeebled,  and  in  those  occurring  just 
prior  to  death,  large  portions  of  the  lung-tissue  may  collapse  simply 
from  inability  to  breathe  with  sufficient  force.  We  also  meet  with 
collapse  of  the  lung  in  whooping-cough,  in  compression  of  the  lung 
from  pleural  effusion,  and  in  rhachitis. 

The  physical  signs  of  collapse  are  not  satisfactory ;  the  symptoms 
vary  with  the  conditions  producing  the  disease.  Neither  voice  nor 
respiration  is  characteristic.  The  most  usual  physical  sign  is  dulness 
on  percussion,  with  an  absence  of  all  respiration,  or  with  a  blowing 
sound,  which  is  faint  and  not  so  distinct  as  in  pneumonia.  The  dul- 
ness is  not  so  great,  may  be  changed  during  respiratory  percussion, 
and  in  cases  dependent  upon  inspissated  mucus  may  disappear  sud- 
denly when  the  obstructing  cause  is  removed.  Yet  collapse  of  the 
lung  is  at  times  a  state  of  long  duration.  Should  a  pneumonic  process 
affect  the  collapsed  portion,  the  dulness  is  stationary,  and  we  are  apt 
to  find  the  high  but  variable  temperature  of  broncho-pneumonia. 
Under  ordinary  circumstances  the  temperature  is  normal  or  sub- 
normal. 

After  collapse  the  breathing  becomes  very  difficult.  The  patient 
makes  intense  efforts  at  inspiration ;  owing  to  the  non-expansion  of 
the  lung  during  these  efforts,  the  ribs  move  inward  and  recede, 
instead  of  moving  outward  as  in  ordinary  breathing.  This  sign,  the 
suddenly  increased  dyspnoea,  and  the  appearance  of  dulness  in  special 
areas,  unaccompanied  by  marked  bronchial  breathing,  are,  in  a  case 
of  bronchitis,  the  most  trustworthy  indications  that  collapse  of  the 
lung-tissue  has  taken  place.  Yet  where  the  collapsed  lobules  are 
small  and  scattered  through  the  lung,  these  signs  are  not  at  all  present, 
and  the  diagnosis  is  uncertain.  The  dulness  is  wanting ;  and  the 
peculiarity  in  inspiration  may  not  be  observed. 

When  collapse  affects  a  large  portion  of  lung,  it  much  resembles 
lobar  pneumonia.  The  fever,  the  absence  of  retraction  of  the  chest 
wall,  the  crepitant  rales,  the  tubular  breathing,  distinguish  this,  and 
bronchophony  is  much  more  marked.  How  nearly  collapse  resembles 
broncho-pneumonia  has  already  been  indicated.  The  diminution  in 
volume  of  portions  of  the  chest,  the  shifting  character  of  the  physical 
signs,  and  the  speedy  re-entrance  of  air  into  parts  that  had  shown 
signs  of  condensation,  are  the  most  trustworthy  points  in  diagnosis. 
In  pleural  effusions  the  distinguishing  signs  are  the  flatness  on  percus- 


DISEASES  OF  THE   LUNGS.  313 

sion  and  the  absence  of  breath-sounds,  of  bronchophony,  of  fremitus  ; 
besides,  we  do  not  find  the  retraction  of  the  chest  walls,  and  the 
extremely  rapid,  superficial  breathing. 

Diseases  in  which  Dulness  on  Percussion  occurs. 

The  diseases  of  the  lungs  in  which  dulness  on  percussion  is  met 
with  are  all  those  in  which  compression  or  consolidation  of  the  pul- 
monary tissue  takes  place.  Especially  do  we  find  dulness,  and  the 
physical  signs  which  accompany  it,  in  the  phthises,  in  pneumonia, 
and  in  pleurisy. 

Phthisis. — Phthisis  presents  itself  in  a  chronic  and  in  an  acute 
form.  The  chronic  variety  is  by  far  the  most  frequent.  It  is  essentially 
"  the  consumption,"  which  is  such  a  scourge  to  the  human  race.  In 
by  far  the  greatest  number  of  instances  this  consumption  is  linked  to 
tubercular  disease.  And  although  we  can  recognize  a  non-tubercular 
form,  I  shall,  unless  it  be  otherwise  specified,  use  the  term  phthisis  as 
meaning  tubercular  disease. 

Beginning  usually  with  a  short  and  insidious  cough,  with  a  feeling 
of  lassitude,  and  a  decline  in  general  health ;  attended  at  times  from 
the  onset  with  a  pain  in  the  affected  lung  and  a  somewhat  quickened 
circulation ;  or  giving  the  first  indications  of  its  existence  by  the 
occurrence  of  a  hemorrhage, — the  disease  becomes  fully  estabhshed, 
with  symptoms  which  hardly  need  a  detailed  description.  The  harass- 
ing cough  ;  the  disturbed  digestion  ;  the  steadily  augmenting  debility  ; 
the  short  breathing ;  the  exhausting  night-sweats ;  the  hectic  fever ; 
the  deceptive  blush  which  this  imparts  to  the  cheek ;  the  increased 
lustre  of  the  eye ;  the  singular  hopefulness  ;  the  temporary  improve- 
ments ;  the  relapses  ;  and  the  greater  vividness  of  the  imagination,  so 
strongly  contrasting  with  the  waning  frame, — are  phenomena  with 
which  sad  experience  has  made  not  only  every  physician,  but  many 
a  fireside,  familiar. 

The  most  constant  of  all  the  symptoms  are  the  hemorrhage,  the 
cough,  and  the  emaciation.  The  cough  is  at  first  dry,  or  followed 
by  a  frothy  expectoration.  As  the  disease  advances,  the  sputa 
thicken.  They  become  greenish  in  color,  streaked  with  yellow,  and 
"  nummular,"  consisting  of  large  greenish  masses  of  a  rounded  form, 
which  do  not  sink  in  the  cup  containing  them,  but  float  imperfectly  in  a 
thin  serum.  This  expectoration  is,  however,  by  no  means  pathogno- 
monic ;  it  is  occasionally  encountered  in  chronic  bronchitis.  In  the 
last  stages  of  consumption  the  sputa  are  often  homogeneous,  and 
have  a  grayish,  purulent  aspect.  Examined  microscopically,  they 
show  alveolar  epithelium,  pus-cells,  exudation  corpuscles,  and  elastic 

20 


314  MEDICAL  DIAGNOSIS. 

tissue,  the  most  distinctive  of  wliich  is  the  elastic  tissue  of  the  alveolar 
walls.  Yet  the  only  absolute  sign  in  the  sputum  is  the  bacillus  tuber- 
culosis. Its  presence  bespeaks  tubercular  disease,  its  absence,  on 
several  examinations,  is  a  strong  argument  against  the  existence  of 
this  affection.  The  numbers  found  in  the  sputum  bear  a  direct  rela- 
tion to  the  extent  and  gravity  of  the  complaint ;  in  arrested  tubercle 
they  become  very  few  or  disappear.  In  lung  destruction  from  syphilis 
or  from  chronic  pneumonia,  in  the  non-bacillary  form  of  fibroid 
phthisis,  in  cavities  from  bronchial  dilatation,  in  gangrene  of  the  lung, 
the  bacillus  is  not  observed.  But  failure  to  fmd  the  bacillus  is  not  as 
valuable  and  conclusive  evidence  as  fmding  it ;  yet  a  few  of  the  bacilli 
may  be  met  with  in  the  sputum  from  accidental  lodgement  in  the  air- 
passages. 

In  rare  instances,  the  cough  remains  slight  throughout  the 
malady ;  but  generally  it  is  a  distressing  feature,  and  is  particularly 
worrying  at  night.  Sometimes  its  violent  paroxysms  bring  on  vomit- 
ing. But  vomiting  and  other  gastric  symptoms  occur  irrespective  of 
paroxysms  of  coughing.  In  truth,  anorexia,  nausea,  and  vomiting  are 
often  very  prominent  and  early  symptoms,  and  may  exist  where  no 
obvious  lesion  of  the  gastric  mucous  membrane  is  found  ;  dilatation 
of  the  stomach  attending  the  dyspeptic  symptoms  is  not  uncommon. 
Some  shortness  of  breath  is  usual ;  dyspnoea  is  rare.  Early  anaemia, 
with  increase  of  the  blood-plates,  is  another  frequent  symptom. 

Among  the  less  constant  symptoms  of  pulmonary  consumption  are 
a  troublesome  and  rebellious  diarrhoea  connected  with  catarrhal  in- 
flammation, with  fistula  in  ano,  or  with  tuberculosis  of  the  bowel, 
chronic  laryngitis  and  chronic  pharyngitis,  hypertrophy  of  the  mam- 
mary gland,  more  common  in  men  than  in  women,  and  the  red  line 
around  the  border  of  the  gum.  In  some  persons  this  gingival  line  is 
a  mere  streak  ;  in  others  it  is  more  than  a  line  in  breadth  ;  in  none  is 
it  a  certain  indication.  A  sign  which  has  a  much  more  definite  con- 
nection with  tubercular  disease  of  the  lungs  is  the  appearance  of  the 
nails.  The  end  of  the  finger  is  somewhat  clubbed  ;  the  nail  is  curved, 
prominent  in  the  centre,  depressed  at  the  sides,  its  surface  slightly 
cracked,  its  appearance  bluish.  A  similar  nail  is,  however,  seen  in 
chronic  pleurisy  and  in  diseases  of  the  heart.  The  laryngeal  symp- 
toms are  apt  to  be  a  very  distressing  complication,  and  mostly  end, 
no  matter  how  they  begin,  in  tubercular  laryngitis.  This,  and  the 
laryngoscopic  appearance  of  the  ulcers  have  been  described  when 
treating  of  laryngeal  diseases. 

Fever  is  a  very  constant  and  significant  symptom  of  pulmonary 
tuberculosis.     Indeed,  the   temperature  may  be  greatly  elevated  for 


DISEASES  OF  THE   LUNGS.  315 

several  weeks  before  we  find  physical  signs  indicative  of  the  depo- 
sition of  tubercle,  or  of  an  undoubted  increase  in  the  already  existing 
deposition.  Furthermore,  the  rise  in  the  body  heat  closely  corre- 
sponds to  the  activity  of  the  deposition  of  tubercle.  If  the  tempera- 
ture be  decidedly  and  permanently  elevated  throughout  the  day,  there 
is  active  deposition.  When  the  temperature  is  normal,  the  deposition 
in  the  lungs  has  ceased,  and  the  tubercular  process  is  arrested  or 
retrograding.  It  may  be  also  normal  or  even  subnormal  in  very 
chronic  cases. 

The  morning  temperature  in  tubercular  phthisis  is  often  higher 
than  the  evening  temperature,  though  we  frequently  see  the  reverse. 
Very  generally  the  maximum  temperature  is  reached  in  the  after- 
noon ;  sweats  occur  in  the  evening,  and  there  is  a  drop  of  two  or 
three  degrees  towards  morning.  The  temperature  chart  of  the  hectic 
fever  may  simulate  that  of  a  remittent  or  an  intermittent  fever,  and 
the  frequent  occurrence  of  chills  and  the  sweats  make  the  resem- 
blance still  closer.  In  the  last  days  of  the  disease  the  temperature 
may, fall  greatly. 

The  thermometer  has  been  made  use  of  in  another  manner  in  the 
diagnosis  of  tubercular  consumption.  Peter  ^  calls  attention  to  the 
advantage  of  local  thermometry.  A  surface  thermometer  is  applied 
firmly  in  front  of  the  chest  in  the  second  intercostal  space,  and  if  the 
temperature  is  higher  there  than  on  the  other  side,  or  than  normal^ 
it  is  because  there  are  tubercles  underneath.  In  beginning  tubercu- 
losis the  increased  local  heat  is  in  proportion  to  the  extent  of  the 
lesions.  In  health  the  temperature  of  the  chest  walls  is  about  36°  C. 
(96.8°  F.) ;  it  may  rise  in  tubercle  to  37°  C,  or  more,  and  in  con- 
sumption with  cheesy  degeneration  still  higher,  surpassing  the  general 
fever  heat  of  the  body. 

The  symptoms  which  precede  a  fatal  termination  are  various. 
Patients  may  go  on  failing  for  years  ;  or  an  intercurrent  attack  of  acute 
tuberculosis,  of  pneumonia,  of  tubercular  meningitis,  or  of  tubercular 
ulceration  of  the  intestines,  may  at  any  time  result  in  death. 

The  tendency  of  tubercular  matter  is  to  soften  and  destroy  the 
textures  among  which  it  is  infiltrated.  It  may  undergo,  at  any  period 
in  its  course,  a  retrogressive  development,  by  shrivelling  up,  or  by 
passing  into  a  calcareous  state.'  When  situated  in  the  lungs,  it  seeks 
the  apices  by  preference  ;  it  is  rarely  limited  to  one  lung,  although 
one  lung  is  usually  the  most  diseased,  and  often  at  the  beginning  of 
the  malady  is  alone  affected.     Tuberculosis  is  not  merely  a  local  com- 

^  Clinique  Medicale,  tome  ii.,  1879. 


316 


MEDICAL   DIAGNOSIS. 


plaint,  but  stands  in  connection  with  a  peculiar,  tainted  state  of  the 
constitution,  whether  this  be  produced  by  infection  from  the  products 
of  the  bacilli  or  not ;  hence  the  symptoms  of  phthisis  are  not  solely 
the  expressions  of  the  condition  of  the  lungs. 

In  accordance  with  the  laws  affecting  tubercular  depositions,  we 
have  three  stages  of  phthisis,  which  are  to  be  borne  in  mind  when 
examining  the  physical  signs  : 

1.  Incipient  stage,  or  beginning  deposition  ; 

2.  More  complete  deposition,  occasioning  consolidation  ; 

3.  Stage  of  softening  and  of  the  formation  of  cavities. 

Fig.  33. 


Slight  percussion  dulness. .  ^ 
Feeble  or  harsh  respiration. 
Prolonged  expiration 


Exaggerated  respiration  . . 


Beginning  infiltration ;  masses  of  tubercle  have  accumulated,  but  the  intervening  lung-tissue  is 

still  healthv. 


1.  A  few  scattered  tubercles  do  not  change  the  normal  percussion 
resonance ;  nor  do  they  appreciably  alter  the  natural  breath-sounds. 
But  as  soon  as  the  deposit  is  sufficient  to  impair  the  elasticity  of  the 
lung-tissue  or  to  increase  its  density,  a  relative  loss  of  clearness  on 
percussion  on  one  side,  and  modifications  of  the  vesicular  murmur, 
such  as  feeble  or  jerking  inspiration,  or  a  prolonged  expiration,  may 
be  ascertained.  The  dulness  is  readily  detected  by  percussing  the 
patient  with  his  mouth  open  and  during  a  fixed  expiration,  or  the 
difference  between  the  two  sides  becomes  very  manifest  during  held 
inspiration, — in  other  words,  respiratory  percussion  will  aid  us.  To 
find  the  dulness  at  the  upper  part  of  the  chest  posteriorly,  the  position 


DISEASES  OF  THE   LUNGS.  317 

of  crossing  the  arms  and  clasping  the  shoulders  is  very  advantageous. 
In  a  certain  number  of  cases,  with  the  slight  dulness  on  percussion 
and  the  changed  breathing  is  associated  a  blowing  sound  in  the  sub- 
clavian or  in  the  pulmonary  artery.  A  murmur  is,  indeed,  at  times 
present  in  the  pulmonary  artery  long  before  any  other  physical  indi- 
cation of  tubercle  is  discernible.  All  these  physical  signs  may  be 
accompanied  by  rales  of  various  kinds.  What  makes  them  significant 
is,  that  they  occur  at  the  upper  portion  of  the  lung,  whether  anteriorly 
or  posteriorly.  If,  therefore,  any  modification  of  the  vesicular  mur- 
mur, or  any  adventitious  sound  limited  to  the  apex,  exist ;  if  there  be 
a  slight  dulness  on  percussion  above  or  under  the  clavicle,  or  in  the 
supraspinous  fossa ;  if  this  coincide  with  flattening  of  the  anterior 
surface  of  the  chest,  especially  on  one  side,  with  defective  expansion 
of  the  thorax  and  shortness  of  breath,  with  a  cough,  and  falling  off 
in  general  health, — the  diagnosis  of  beginning  tubercular  disease  is 
almost  positive.  But  these  signs  possess  now  less  value  to  us  than 
formerly,  for  the  detection  of  bacilli  would  be  of  greater  import  than 
any  or  all  of  them. 

2.  As  the  infiltration  advances,  the  signs  become  more  decidedly 
those  of  consolidation.  Greater  dulness  on  percussion  at  the  upper 
portion  of  one  or  of  both  lungs,  scarcely  influenced  by  respiratory 
percussion  ;  more  resistance  to  the  percussing  finger ;  stronger  vocal 
resonance  ;  a  sinking  in  of  the  side  most  affected,  and  often  soreness 
to  the  touch  over  the  diseased  part ;  a  very  harsh  murmur ;  or,  when 
the  infiltration  surrounds  the  bronchial  tubes,  a  distinct  blo^^4ng  res- 
piration,— are  all  present  in  varying  degree,  and  all  denote  consolida- 
tion. And  chronic  consolidation  at  the  apex  has,  in  the  large  ma- 
jority of  instances,  but  one  interpretation, — phthisis.  In  the  second 
stage,  as  well  as  in  the  first,  we  often  meet  with  superadded  signs  of 
bronchitis  which  occasionally  mask  the  respiratory  sounds,  with  fric- 
tion-sounds from  local  pleurisies,  or  mth  fine  crackling.  We  may 
also  encounter  a  whiffing  murmur,  the  so-called  cardio-pidmonary 
murmur  produced  by  the  beat  of  the  heart  against  the  pulmonary 
texture,  and  especially  heard  in  inspiration. 

3.  The  diseased  organ  now  passes  into  a  state  of  softening,  or 
rather  some  portions  of  the  lung  begin  to  soften,  while  others  remain 
indurated,  and  in  yet  others  -fresh  infiltration  takes  place.  Moist 
crackling  or  persistent  moist  rales  indicate  that  softening  has  begun. 
The  broken-down  material  may  be  expectorated,  and  the  malady  for 
a  time  be  stayed ;  but  such  is  not  often  the  case.  The  area  of  the 
softened  mass  widens  ;  cavities  form  ;  and  in  addition  to  the  moist 
rales,  to  the  physical  phenomena  of  the  second  stage,  and  to  the  in- 


318 


MEDICAL   DIAGNOSIS. 


creasing  debility,  night-s^Yeats,  and  hectic,  the  signs  indicative  of  a 
cavity  are  noticed.  Prominent  among  them  are  the  cavernous  voice, 
especially  in  whispering,  and  the  hollow  breathing.  But  the  hollow, 
cavernous  respiration  may  be  caught  only  in  expiration,  or  it  may  be 
temporarily   superseded   by   very   large   bubbliiig   sounds, — gurgling. 

Fig.  34. 


Cavernous 
respiration. 

Gurgling. 

Cavernous 
voice. 


Cavities  of  various  sizes. 


Again,  over  small  or  over  deep-seated  canities  none  of  these  sounds 
may  be  perceived ;  and,  in  truth,  even  when  they  exist,  their  limita- 
tion to  a  particular  locality  is  an  element  in  the  diagnosis  of  a  cavity 
almost  as  important  as  their  presence. 

The  results  of  percussion  over  an  excavation  are  not  always  the 
same.  They  depend  much  on  the  thickness  and  the  state  of  the  walls 
of  the  cavity.  If  dense,  percussion  yields  a  dull  sound :  if  thin,  a 
tympanitic,  or  its  varieties,  a  cracked-pot  or  a  metallic  sound.  If 
only  a  certain  amount  of  indurated  tissue  intervene  between  the 
cavity  and  the  surface  of  the  chest,  a  singular  sound,  a  mixture  of 
dull  and  tympanitic,  is  produced.  If  healthy  lung-tissue  form  the 
walls  of  the  excavation,  the  sound  is  clear,  or  nearly  so.  Moreover, 
in  all  cases  the  pitch  and,  to  some  extent,  the  character  of  the  sound 
are  changed  by  percussing '  over  the  cavity  while  the  mouth  is  kept 
open.  When  it  is  shut,  the  sound  elicited  is  of  lower  pitch.  On 
inspiratory  percussion,  the  previously  tympanitic  or  mixed  sound  be- 
comes dull.     Another  sign  by  which  we  may  judge  of  the  existence 


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DISEASES   OF  THE   LUNGS.  319 

of  a  cavity  at  the  upper  part  of  the  lung  is  the  extraordinary  clear- 
ness with  which  the  heart-sounds  are  heard  at  that  point,  or  a  waving 
impulse  in  the  second  intercostal  space.  Yet  another  sign  of  the 
cavity  is  marked  leucocytosis.  In  early  phthisis,  and  prior  to  soften- 
ing, the  white  corpuscles  are  in  normal  proportion,  and  remain  so 
until  cavities  form,  except  in  intercurrent  exudative  inflammatory 
processes/ 

There  is  a  cjuestion  whether  we  can  recognize  a  pretubercular 
stage.  But,  unless  we  found  the  bacillus  of  tubercle  in  instances 
supposed  to  be  pretubercular  on  account  of  defects  of  temperature, 
lessened  muscular  power,  vomiting,  imperfect  assimilation,  emaciation, 
sore  throat,  slight,  dry  cough,  and  of  limited  physical  signs,  we  should 
have  no  proof  that  the  disease  had  anything  to  do  with  consumption. 

The  primary  lesion  is  not  often  in  the  extreme  apex  of  the  lung, 
but  has  its  site  from  an  inch  to  an  inch  and  a  half  below  the  summit 
of  the  lung,  and- rather  nearer  to  the  posterior  and  external  borders.^ 
Lesions  in  this  position  tend  to  spread  backward,  and  thus  is  ex- 
plained why  we  may  have  the  physical  signs  of  deposit  marked  in  the 
supraspinous  fossa  while  they  are  still  uncertain  in  front.  Another 
site  of  primary  affection  is  at  a  spot  corresponding  on  the  chest  wall 
with  the  first  and  second  interspaces  below  the  outer  third  of  the 
clavicle.  The  lower  portion  of  the  lung  is  usually  involved  before  the 
apex  of  the  opposite  lung. 

Let  us  now  look  at  the  disorders  with  which  phthisis,  in  its  various 
stages,  is  likely  to  be  confounded,  premising  that  in  doubtful  cases  the 
diagnosis  is  always  to  be  established  by  the  presence  of  the  tubercle 
bacillus.     They  are,  to  speak  of  thoracic  affections  only : 

Chronic  Bronchitis  ; 

Chronic  Pneumonic  Consolidation  ; 

Chronic  Pleurisy  ; 

Pulmonary  Cancer ; 

Syphilitic  Disease  of  the  Lungs  ; 

Bronchial  Dilatation  ; 

Pulmonary  Abscess  ; 

Pulmonary  Gangrene. 

Actinomycosis. 

Chronic  Bronchitis. — The  first  stage  of  consumption  is  particularly 
prone  to  be  mistaken  for  chronic  bronchitis.  Distinct  dulness  on 
percussion  at  the  apex  is  of  much  aid  in  discrimination,  especially  if 

1  Stein  and  Erbmann,  Deutch.  Arch.  f.  k.  Med.,  1895-96,  p.  366. 
^  Fowler,  The  Localization  of  the  Lesions  of  Phthisis,  London,  1888. 


320  MEDICAL  DIAGNOSIS. 

it  be  on  the  left  side,  and  if  alterations  of  the  vesicular  murmur  cor- 
respond to  it.  When  the  dulness  is  not  discernible,  we  have  to 
depend  on  the  history  of  the  case,  especially  as  to  family,  likelihood 
of  exposure  to  infection,  the  occurrence  of  blood-spitting,  the  limita- 
tion of  the  physical  signs  to  the  apex,  the  persistency  of  the  cough, 
and  the  falling  off  in  general  health,  out  of  proportion  to  the  local 
lesions. 

Where  the  deposition  is  at  all  extensive,  an  erroneous  diagnosis 
of  bronchitis  is  with  ordinary  care  impossible,  unless,  as  is  always 
highly  improbable,  phthisis  should  be  complicated  with  emphysema, 
or  the  tubercles  be  quiescent,  and  so  diffused  as  not  to  impair  the 
resonance  on  percussion.  Under  the  latter  circumstances  especially, 
the  occasional  tympanitic  character  of  the  sound  over  the  seat  of  the 
tubercular  deposition  is  liable  to  be  misconstrued  into  increased  clear- 
ness on  percussion,  and  into  a  disproval  of  the  existence  of  phthisis. 
When  tubercle  and  emphysema  coexist,  the  percussion  note  may 
really  be  pulmonary  and  like  that  of  healthy  lung ;  the  respiratory 
sound  becomes  much  feebler ;  generahy,  too,  the  dyspncea  is  in- 
creased ;  the  temperature  is  higher  than  in  pure  emphysema.  But 
the  most  certain  sign  would  be  the  tubercle  bacilli  in  the  sputum. 

A  difficult  diagnosis  may  be  at  times  the  distinction  between 
chronic  bronchitis  and  the  p)htMsis  of  old  people.  Tliis,  indeed,  often 
happens  in  a  latent  form,  and  is  very  slow  in  its  development ;  the 
temperature  may  be  normal  or  subnormal.  Besides  the  microscopic 
examination  of  the  sputum,  auscultation  alone  is  of  much  value,  since 
the  chest  remains  resonant  on  percussion,  owing  to  the  dwindling  of 
the  muscles  of  the  thorax,  the  ossification  of  the  rD3s,  and  the  rare- 
faction of  the  lungs. 

In  the  stage  in  which  the  signs  of  consolidation  become  well 
defined,  phthisis  may  be  mistaken  for  any  of  those  conditions  that 
occasion  the  physical  signs  indicative  of  greater  density  of  the  lung- 
tissue,  and  that  are  accompanied  by  cough  and  by  loss  of  flesh.  Such 
are  particularly  pneumonic  consolidation,  pleuritic  effusion,  and  can- 
cerous deposits. 

Chronic  Pneumonic  Consolidation. — Chronic  pneumonic  consolida- 
tion, or  chronic  pneumonia,  gives  rise  to  many  manifestations  which 
simulate  consumption.  These  are  cough,  emaciation,  and  the  local 
signs  of  chronic  condensation, — increased  voice  and  fremitus,  sinking 
in  of  the  chest  wall,  feeble  inspiration  and  prolonged  expiration,  or  a 
fully  developed  bronchial  respiration.  But  in  pneumonic  consolida- 
tion the  history  usually  points  to  an  antecedent  acute  affection;  the 
health  is  not   so  much  impaired ;   there  has  been   no  hemorrhage, 


DISEASES  OF  THE  LUNGS.  321 

although  the  sputa  at  times  may  have  been  streaked  with  blood  ;  and 
the  dulness  on  percussion  and  the  other  physical  signs  of  consolida- 
tion are,  for  the  most  part,  perceived  over  the  lower  lobe  of  one  lung. 
In  many  of  these  cases  interstitial  fibroid  changes  ultimately  take 
place  in  the  lung,  and  we  thus  have  a  chronic  interstitial  pneumonia, 
which  allies  the  cases  closely  to  fibroid  phthisis.  Yet  it  is  clinically 
convenient  to  keep  them  apart,  as  the  consolidation  may  slowly  dis- 
appear, and  the  retraction  of  the  chest  and  other  features  of  fibroid 
phthisis  as  ordinarily  seen  are  not  present. 

This  position  of  the  physical  signs  is  of  great  importance.  Yet 
there  are  two  sources  of  fallacy  which  may  arise.  On  the  one  hand, 
tubercles  may,  by  way  of  exception,  be  seated  in  the  lower  lobe ;  on 
the  other,  chronic  pneumonic  induration  may  affect  the  apex.  When 
an  infiltration  of  tubercle  takes  place  in  the  lower  lobe,  its  distinction 
from  chronic  pneumonic  consolidation  is  very  difficult.  Our  surest 
guides  are  attention  to  the  pathological  law  which  teaches  that  con- 
sumption is  not  met  with  in  an  advanced  state  in  one  lung  alone,  and 
the  examination  of  the  sputum  for  bacilli.  Not  finding  these,  and  the 
absence  of  serious  general  symptoms,  will  determine  the  real  nature 
of  the  case  when  an  inflammation  of  the  upper  lobe  has  resulted  in 
its  persistent  induration.  I  adduce  a  few  instances,  by  way  of  illus- 
tration : 

A  gentleman  was  under  my  care  for  years,  in  whom,  after  pul- 
monary mflammation,  signs  of  condensation  remained  in  the  upper 
part  of  the  right  lung.  He  did  not  suffer  at  all,  except  from  attacks 
of  acute  bronchitis,  to  which  he  was  very  liable.  During  these  he 
lost  flesh ;  but  when  they  passed  off  he  rapidly  regained  it.  He  had 
a  chronic  cough,  but  it  was  very  slight.  After  the  lapse  of  a  number 
of  years  I  lost  sight  of  him. 

In  another  case,  with  a  similar  history,  I  found  dulness  on  percus- 
sion, prolonged  expiration,  and  a  friction-sound  limited  to  the  apex  of 
the  right  lung.  There  had  been  a  continuous  cough,  but  very  little 
constitutional  disturbance,  and  no  hemorrhage.  The  abnormal  signs 
lasted  for  a  year,  and  then  almost  disappeared  under  a  succession  of 
blisters,  and  the  cough  ceased.  In  yet  another  patient,  a  man  seventy- 
five  years  of  age,  the  dulness  at  the  right  apex  had  for  years  remained 
stationary. 

In  all  instances  of  doubt  between  chronic  induration  and  tulDer- 
cular  disease,  important  information  is  drawn  from  watching  whether 
the  physical  signs  undergo  changes  in  the  hitherto  healthy  portions 
of  the  lung.  To  the  presence  or  absence  of  the  bacillus  tuberculosis 
in  the  sputum  the  greatest  weight  must  be  attached. 


322  MEDICAL  DIAGNOSIS. 

A  great  and  complicating  difficulty  in  ttie  differential  diagnosis 
grows  out  of  the  circumstance  that  tubercular  disease  may  be  devel- 
oped in  a  lung  in  a  state  of  chronic  induration.  We  find  persons  in 
good  health  seized  with  inflammation  of  the  lung,  which  is  followed 
by  persistent  consolidation,  and  in  the  course  of  time  by  tubercular 
phthisis.  Indeed,  many  of  the  reported  cases  of  tubercle  affecting 
primarily  the  lower  lobe  of  the  lung  are,  in  reality,  cases  of  tubercu- 
losis following  chronic  pneumonic  consolidation.  The  history  is 
usually  as  follows.  A  person  in  all  respects  healthy  is  attacked  with 
an  acute  pulmonary  affection.  He  recovers  from  it.  but  with  a  trifling 
cough,  with  a  persistent  dnlness  on  percussion,  and  with  feeble 
respiration,  heard  over  a  portion  of  one  of  his  lungs.  He  continues 
ailing,  though  not  positively  ill,  when,  without  any  apparent  cause, 
after  a  time  varying  from  a  few  months  to  years,  his  cough  increases, 
the  expectoration  augments  greatly  and  becomes  decidedly  purulent, 
the  temperature  rises,  and  he  emaciates  rapidly.  Hemorrhage  may 
or  may  not  happen  ;  profuse  night-sweats  occur ;  and  the  physical 
signs,  which  have  been  stationary  for  a  long  time,  now  begin  to 
change.  The  dulness  extends  :  and,  instead  of  the  enfeebled  respi- 
ration, a  harsher,  blowing  respiration  is  perceived  over  the  affected 
part,  and  moist  crackling  and  the  signs  of  a  ca^dty  follow.  If  doubt 
still  exist  as  to  the  nature  of  the  malady,  the  advance  of  the  disease 
will  clear  it  up.  True  to  the  laws  of  tuJDercle,  a  deposit  takes  place 
in  the  lung  previously  sound,  and  not  at  the  lower  portion,  but  at 
its  apex. 

At  all  stages  a  minute  examination  of  the  sputum  will  tell  us  when 
the  bacillar  mfection  takes  place.  It  is  supposed  by  many  that  the 
tubercle  bacilli  have  existed  in  the  lung  prior  to  the  inflammatory  dis- 
ease, or  may,  indeed,  have  caused  it.  But  this  is  not  often  borne  out 
by  the  clinical  histor}\  It  is  more  likely  that  the  bacilli  have  lodged 
in  the  damaged  organ.  Cases  of  the  kind  with  the  cheesy  changes  in 
the  lung  and  the  cUsmtegrating  products  of  the  mflammation  form  the 
variety  of  phthisis  that  was  not  long  since  asserted  to  be  a  special  dis- 
ease, jj^eu/yio/uVj^/^^A  ?.§/.$•.  but  which  we  no  longer  doubt  to  be  only  a 
clinically  somewhat  different  variety  of  tubercular  affection. 

These  remarks  apply  almost  equally  whether  the  original  seizure 
was  a  croupous  pneumonia  or  a  catarrhal  pneumonia.  Yet  there  are 
some  special  points  wliich  the  chronic  consolidation  attending  a  chronic 
catarrhal  pneumonia  exhibits.  In  the  first  place,  the  history  of  a  pre- 
ceding acute  catarrhal  attack  is  clear,  or  there  have  been  a  series  of 
attacks,  after  one  of  wliich  the  lung  was  left  solid,  and  since  which 
the  patient   has  been   prone  to  take  cold,  and   is  easily  put  out  of 


DISEASES  OF  THE  LUNGS.  323 

breath.  Now,  he  may  come  under  our  observation  in  the  midst  of 
one  of  these  broncho-pneumonic  seizures,  and  we  may  watch  him  for 
months  with  the  signs  of  consohdation  over  a  portion  of  one  lung, 
whether  at  base  or  apex,  or  with  affected  points,  often  symmetrical, 
in  both ;  further,  there  are  night-sweats,  fever  with  decided  evening 
exacerbation,  diarrhoea.  Gradually  these  urgent  symptoms  yield ;  he 
gets  about,  but  a  spot  or  spots  of  consolidation  in  one  or  both  lungs 
do  not  go  away  for  a  long  time :  or  the  chronic  catarrhal  pneumonia 
may  remain  as  such,  or  pass  into  pneumonic  phthisis,  which  really 
means  tubercle.  When  this  happens,  great  variation  between  morn- 
ing and  evening  temperature,  simulating  a  malarial  fever,  increasing 
cough  and  dyspnoea,  marked  sweats,  decided  emaciation,  announce 
the  event :  while  the  physical  signs  show  extending  dulness,  cracklmg 
and  fine  moist  rales,  over  the  affected  spots  or  in  parts  not  previously 
diseased,  and  ultimately  cavities.  At  all  stages  repeated  examinations 
of  the  sputum  for  tubercle  bacilli  are  of  decisive  value. 

Chronic  Pleurisy. — A  persistent  cough  attended  with  emaciation 
and  with  dulness  on  percussion  is  common  to  chronic  pleurisy  and  to 
phthisis,  and  is  a  cause  of  many  errors.  But  the  seat  of  the  dulness 
at  the  lower  part  of  the  thorax  ;  its  much  more  absolute  character ; 
the  almost  entire  cessation  of  all  breath-sound ;  the  diminished  or 
absent  vibration  of  the  chest  walls  when  the  patient  speaks ;  the  dila- 
tation of  the  affected  side, — are  in  striking  contrast  with  signs  most 
manifest  at  the  apex,  with  the  distinctly  prolonged  expiration,  with 
the  rales  and  the  evidences  of  beginning  softening.  Nor  are  the 
symptoms  of  a  pleuritic  effusion  as  grave  as  those  produced  by 
phthisis.  Even  where  the  fluid  filling  the  chest  is  pus,  we  do  not 
find  hectic  fever  so  intense,  emaciation  so  great,  or  night-sweats  so 
constant  and  exhausting ;  and  the  patient  coughs  less,  and  never  spits 
up  blood.  In  those  cases  of  chronic  pleurisy  in  which  the  side,  in- 
stead of  being  dilated,  is  retracted,  the  diagnosis  is  more  difficult. 
Attention  to  the  seat  of  dulness  being  at  the  lower  part  of  the  chest, 
to  the  diminished  respiration,  voice,  and  fremitus,  and  to  the  shrinking 
affecting  only  one  side  of  the  thorax,  will,  however,  serve  as  the 
foundation  for  a  correct  conclusion. 

Tubercle  may  complicate  pleuritic  effusions.  We  suspect  this  by 
the  occurrence  of  hemorrhage,  .and  by  the  marked  emaciation  and 
hectic.  We  can  only  be  sure  of  it  by  finding  signs  of  deposit  on  the 
non-affected  side,  and  by  tubercle  bacilli  in  the  sputum.  Tubercular 
pleurisy  may  be  a  one-sided  as  well  as  a  primary  disease.  It  is  not 
always  accompanied  by  effusion.  There  may  be  only  great  and 
irregular  thickening  of  the  pleural  membrane  attended  with  variable 


324  MEDICAL  DIAGNOSIS. 

fever,  with  coarse  Mction,  with  much  pain,  and  mth  or  without  bacilH 
in  the  scanty  expectoration.  Chronic  double  pleurisy  is  very  apt  to 
be  associated  with  a  tubercular  affection  of  the  lungs,  but  it  may  be 
rheumatic,  or  may  occur  without  obvious  cause. 

Pulmonary  Cancer. — Cancer  of  the  lung  shares  with  tubercle  the 
cough,  night-sweats,  hemorrhage,  gradual  wasting,  as  well  as  the 
signs  of  pulmonary  consolidation.  But  cancerous  formations  are 
usually  limited  to  one  lung.  Only  one  side  of  the  chest  is  flattened 
or  distended.  Over  the  cancerous  lung  the  percussion  dulness  is 
great.  There  is  either  loud,  blowing  respiration,  or,  if  the  mass  have 
compressed  or  obliterated  a  bronchus,  enfeebled  or  absent  breathing 
and  absent  tactile  fremitus.  We  find  no  rales  ;  but  all  the  signs  of 
consolidation  are  more  perfect  than  in  tubercle.  Owing  to  a  cancerous 
deposit  in  the  mediastinum,  the  dulness  at  times  extends  beyond  the 
median  line.  Paroxysmal  dyspnoea,  enlargement  of  the  clavicular 
lymph-glands,  and  prominence  of  the  large  veins  on  the  chest  and 
arms  are  common.     Fever  is  generally  absent. 

Cancer  in  the  lung  may  soften ;  yet  the  signs  of  softening  are 
rarely  as  manifest  as  they  are  in  tubercle.  The  sputa  are  purulent, 
or  like  currant-jelly  or  prune-juice,  and  show  no  characteristic  bacilli. 
Further,  a  cancerous  tint  of  the  skin  may  be  present ;  and  cancerous 
tumors  in  other  parts  of  the  body  become  absolute  evidence  in  favor 
of  a  deposit  in  the  lung  being  cancerous,  since,  with  very  rare  ex- 
ceptions, cancer  and  tubercle  do  not  coexist.  The  character  of  the 
pain  must  be  also  taken  into  account.  In  tubercle,  it  is  transitory 
and  shifting ;  in  cancer,  it  is  much  more  constant,  and  much  more 
severe. 

Syphilitic  Disease  of  the  Lungs. — Syphilis  may  occasion  a  specific 
form  of  bronchitis,  preceding  the  syphilitic  eruption ;  or  produce 
gummata,  which  may  soften  and  be  eliminated,  and  which  form  in 
the  lungs  towards  their  periphery  and  base  ;  or  give  rise  to  chronic 
interstitial  pneumonia  of  the  base.  When  syphilis  manifests  itself 
in  the  pulmonary  structures,  it  produces  most  of  the  phenomena  of 
phthisis.  The  chief  differences  are,  that  the  nodules  affect  generally 
only  one  lung,  most  frequently  the  right,  and  principally  the  base  or 
the  lower  part  of  the  upper  lobe  ;  that  they  remain  circumscribed,  not 
spreading  to  the  surrounding  textures  ;  and  that  they  occasion,  as  a 
rule,  neither  liEemoptysis,  nor  fever,  nor  night-sweats,  nor  decided 
emaciation,  nor  marked  cough  or  rales,  but  dyspnoea  out  of  proportion 
to  the  local  disease.  The  most  common  physical  signs  are  dulness 
on  percussion,  deficient  fremitus,  altered  vesicular  breath-sounds, 
and  obvious  sinking  in  of  the  supra-  and  infraclavicular  regions  ;  in 


DISEASES  OF  THE  LUNGS.  325 

some  instances  signs  of  destruction  of  the  lung  are  found.  Still,  the 
syphilitic  affection  can  be  distinguished  with  certainty  only  by  the 
history  of  the  case,  by  the  thickening  of  the  periosteum  of  the  head 
of  one  or  both  clavicles,  and  the  perichondrium  of  one  or  more  of 
the  upper  cartilages,  with  frequently  a  tumefaction  of  the  soft  parts 
between  them  and  the  skin,  and  by  substernal  tenderness.  In  all 
cases  we  must  be  careful  that  the  thickening  at  the  upper  part  of  the 
chest  walls  and  the  altered  resonance  thus  occasioned  be  not  looked 
upon  as  signs  of  a  tubercular  consolidation ;  and  as  regards  the  ten- 
derness, pain  on  pressure  is  met  with  at  the  lower  part  of  the 
sternum  in  a  large  number  of  phthisical  cases. 

Syphilis  of  the  lung  may  also  be  associated  with  syphilitic  lesions 
in  other  organs,  especially  in  the  larynx,  and  we  may  find  considerable 
cough,  with  emaciation,  diarrhoea,  and  albuminuria.  But  even  then 
there  are  no  night-sweats  and  fever  attending  the  emaciation,  the  great 
debility,  and  the  marked  dyspnoea.  The  diagnosis  of  syphilis  has 
been  made  by  microscopical  examination  of  the  sputum,  finding 
nucleated  granular  cells,  shrivelled  nuclei,  spindle-cells,  and  remnants 
of  a  finely  striated  stroma.^  To  the  absence  of  tubercle  bacilh  in 
doubtful  cases  great  weight  must  be  attached.  Fibrous  pleurisy  and 
pleuritic  effusions  are  comparatively  frequent ;  even  small  cavities 
occur  in  the  lung.^  In  rare  instances  syphilis  of  the  lung  runs  an 
acute  course,  simulating  acute  pneumonic  phthisis. 

The  preceding  diseases  are  most  likely  to  be  confounded  with  the 
stages  of  consumption  prior  to  softening  and  the  formation  of  cavi- 
ties. Next  let  us  review  those  affections  which,  like  phthisis,  occasion 
the  signs  of  excavation,  and  which,  therefore,  may  be  mistaken  for 
its  third  stage :  they  are,  chiefly,  bronchial  dilatation,  abscess,  and 
gangrene  of  the  lung. 

Bronchial  Dilatation. — A  dilatation  of  the  bronchial  tubes  takes 
place  in  two  forms :  either  the  tubes  are  uniformly  dilated  and  like 
the  fingers  of  a  glove,  or  else  they  form  cavities  by  undergoing  a  sac- 
cular enlargement.  The  former  variety  furnishes  the  symptoms  and 
physical  signs  of  a  case  of  chronic  bronchitis  attended  with  copious 
expectoration.  The  percussion  clearness  may  be  slightly  lessened, 
owing  to  the  condensation  of  the  surrounding  pulmonary  tissue ;  the 
respiration  may  be  more  strictly 'bronchial ;  but  otherwise  both  symp- 
toms and  signs  are  those  of  chronic  bronchial  inflammation.     In  the 

^  Sokolowsky,  Deutsche  Medicinische  Wochenschrift,  Sept.  12,  1883  ;  Cube, 
also  Guntz,  quoted  in  Schmidt's  Jahrbuch,  No.  6,  1882. 

^  Satterthwaite,  Boston  Medical  and  Surgical  Journal,  June,  1891. 


326  MEDICAL  DIAGNOSIS. 

globular  form  of  dilatation  we  meet  with  all  the  sounds  of  tubercular 
excavations  :  the  hollow,  blowing  respiration  ;  the  hollow,  well-trans- 
mitted voice  ;  gurgling ;  even  metallic  tinkling.  In  the  acute  cases, 
Wilson  Fox  ^  has  observed  the  metaUic  quality  of  the  rales  to  be  very- 
distinctive.  Yet  all  these  phenomena  are  in  strange  contrast  with  the 
almost  unimpaired  health,  and  with  the  non-occurrence  of  hemor- 
rhage, of  night-sweats,  and  of  emaciation.  Still  hemorrhage  does 
happen  in  a  certain  proportion  of  the  cases.  Pain,  Lebert  has  shown, 
is  among  the  early  manifestations  of  the  disease.  The  temperature 
is  normal,  except  during  acute  or  subacute  attacks  of  bronchial  in- 
flammation. 

Thus,  when  we  find  the  signs  of  a  cavity,  and  when  the  general 
symptoms  do  not  indicate  profound  constitutional  disturbance,  we 
may  suspect  a  bronchial  dilatation.  This  suspicion  becomes  a  cer- 
tainty, if  the  cavity  be  at  the  middle  or  the  lower  portion  of  the  lung, 
if  the  resonance  on  percussion  be  but  little  impaired,  and  if  the  slight 
dulness  is  not  increased  by  inspiratory  percussion,  and,  for  the  most 
part,  follows,  and  does  not  precede,  the  auscultatory  signs  of  a  cavity. 
We  find  further  evidence  in  the  stationary  character  of  the  physical 
signs  :  for  months  they  do  not  change.  They  are  often  associated 
with  unilateral  interstitial  pneumonia  or  pleurisy,  and  with  retraction 
of  the  chest.  The  expectoration  of  bronchial  dilatation  is  more 
abundant  than  that  of  consumption,  is  apt  to  be  purulent,  acid,  of 
oily  appearance,  and  in  chronic  cases  fetid,  suggesting,  indeed,  at 
times,  the  existence  of  gangrene.  It  does  not  contain  tubercle  bacilli, 
and  shows  elastic  fibres  only  if  there  be  ulceration.  As  regards  the 
cough  of  dilated  bronchi,  it  is  persistent,  and  only  at  times  relieved 
by  expectoration,  which  varies  in  copiousness  according  to  the  size 
of  the  sac,  and  chiefly  occurs  after  a  spell  of  coughing  in  the 
morning. 

Skoda  ^  describes,  as  a  peculiar  physical  sign  present  in  sacculated 
bronchial  dilatation,  a  large  and  coarse  crackling,  called  by  him  the 
large  bubbling,  dry  crepitant  rale.  In  a  case  which  came  under  my 
observation,  the  diagnosis  was  made  by  this  auscultatory  sign.  The 
patient,  a  boy  aged  twelve  years,  had  swallowed  a  bone,  which 
lodged  in  a  bronchial  tube  and  gave  rise  to  bronchitis  and  bronchial 
widening.  He  died  subsequently  of  acute  meningitis,  and  the  bone 
was  found  firmly  embedded  on  one  side  of  the  globularly  dilated 
bronchial  tube. 


^  Treatise  on  Diseases  of  the  Lungs  and  Pleura,  London,  1891. 
^  Percussion  and  Auscultation. 


DISEASES  OF  THE  LUNGS.  327 

Bronchial  dilatation  is  observed,  as  in  the  instance  just  mentioned, 
after  impacted  foreign  bodies.  It  is  also  met  with  after  whooping- 
cough,  after  long-standing  chronic  bronchitis  in  which  the  bronchus 
has  been  weakened  by  inflammatory  changes,  and  in  connection  with 
cirrhosis  of  the  lung.  But  there  are  many  cases  to  which  Granger 
Stewart^  has  particularly  called  attention  that  are  due  to  atrophy  of 
the  bronchial  wall,  and  that  probably  result  from  a  constitutional 
defect.     In  these  primary  cases  the  disease  comes  on  insidiously. 

Pulmonary  Abscesses. — Abscesses  of  the  lung  may  form  in  the 
course  of  acute  pneumonia,  but  are  not  then  likely  to  be  mistaken  for 
chronic  phthisis.  Different  is  it  with  abscesses  which  are  developed 
three  or  four  months  after  an  attack  of  pneumonia,  and  where  the 
lung-texture  has  remained  partiahy  consolidated.  I  have  seen  not  a 
few  examples  of  chronic  induration  of  the  lung  terminating  in  this 
way.  A  man  who  was  shot  through  the  lung  was  seized,  soon  after 
the  injury,  with  inflammation  of  that  organ.  Percussion  dulness  and 
blowing  respiration  continued  at  the  lower  part  of  the  left  lung.  One 
day,  after  exertion,  he  suddenly  expectorated  a  considerable  amount 
of  pus.  The  signs  of  a  cavity  were  detected  at  once  ;  but  they  sub- 
sequently disappeared,  and  perfect  recovery  took  place.  In  another 
case  of  pneumonia,  the  disease  in  like  manner  lapsed  into  a  chronic 
state.  Five  months  after  the  acute  attack,  the  evidences  of  an  exca- 
vation became  manifest  at  the  edge  of  the  right  scapula,  and  existed 
there  for  two  months  ;  then,  so  far  as  physical  signs  could  prove,  the 
cavity  closed.  Instead  of  the  hollow,  blowing  respiration  and  gur- 
ghng,  only  a  somewhat  roughened  vesicular  murmur  was  perceived. 

Such  is,  however,  not  always  the  termination.  The  abscess  may 
grow  larger  and  larger,  until  the  entire  lung  is  destroyed ;  amphoric 
percussion  note,  amphoric  respiration,  amphoric  voice,  and,  at  times, 
metallic  rales,  being  the  physical  signs  observed. 

Lung  abscesses  differ  from  bronchial  dilatation  in  not  being  perma- 
nent and  fixed.  They  have  this  in  common  with  tubercular  excava- 
tions,— they  change.  They  increase  like  these  ;  but,  further,  they  do 
what  tubercular  cavities  do  not,  they  decrease.  Their  physical  signs 
are  in  every  respect  like  those  of  all  cavities,  and  vary  with  the  size 
of  the  excavation.  Sometimes  metallic  respiration  and  voice  may  be 
heard  over  it;  or  perforation  of  the  pleura  produces  the  signs  of 
pneumothorax  with  effusion.  In  fortunate  instances  the  pus  is  ex- 
pectorated, or  the  abscess  opens  externally,  and  a  cure  is  thus  estab- 
lished.    But  very  large  abscesses  are  apt  to  wear  out  the  patient. 


^  Twentieth  Century  Practice,  vol.  vi. 


328  MEDICAL  DIAGNOSIS. 

Hectic  fever  and  occasional  hemorrhage  attend  them  ;  yet  neither  is  so 
constant  a  symptom  as  it  is  in  consumption.  The  sputa  are  usually 
copious,  purulent,  full  of  elastic  tissue,  and  fetid,  differtag  in  this  re- 
spect from  the  expectoration  of  phthisis,  which  is  only  temporarily 
fetid,  if  the  secretions  decompose  in  the  cavities.  Again,  abscess  of 
the  lung  may  be  distinguished  from  tubercular  disease  by  being  ordi- 
narily situated  at  the  base  of  the  organ ;  by  its  following  pneumonic 
consolidation,  although  there  are  exceptions  to  this  rule,  chiefly  in 
septic  conditions  ;  by  the  occurrence  of  copious  expectoration  being 
often  sudden  ;  but  especially  by  its  limitation  to  one  lung.  The  other 
lung  remains  healthy.  It  may  enlarge,  and  its  murmur  be  more  chs- 
tinct ;  but  the  sounds  denote  its  texture  to  be  normal. 

Abscess  of  the  lung  is  not  infrequent  in  suppurative  diseases  of 
the  nose,  or  larynx,  or  oesophagus.  It  is  still  more  common  from  em- 
bolic infection.  The  small  amount  of  constitutional  disturbance  which 
pulmonary  abscesses  sometimes  entail  is  remarkable,  and  the  physical 
signs  of  a  large  cavity  are  in  strange  contrast  with  the  regular  pulse, 
the  almost  undisturbed  breathing,  the  slight  cough,  and  the  healthy 
complexion. 

What  has  been  called  "  dissecting  pneumonia,"  a  suppurative 
inflammation  starting  mostly  in  the  peribronchial  tissues,  dissecting 
the  lobules,  and  subsequently  destroying  the  parenchyma,  leaving 
nothing  but  the  bronchial  ramifications  and  vessels,  has  symptoms 
that  are  in  the  main  those  of  abscess,  of  w^hich,  indeed,  it  forms  a 
variety.  The  absence  of  fetid  breath  and  of  fetid  sputum  distinguishes 
it  from  gangrene.^ 

Pulmonary  Gangrene. — This  disease  also  yields  the  signs  of  an  ex-' 
cavation.  It  occurs  either  as  diffused  or  as  circumscribed  gangrene, 
after  pneumonia,  especially  aspiration  pneumonia,  or  typhoid  fever, 
after  wounds  of  the  lung,  from  blows  on  the  chest,  from  poisoned 
blood,  diabetes,  pressure  of  an  aneurism,  or  from  emboli  in  the  pul- 
monary tissue.  The  symptoms  are :  great  prostration,  dyspnoea,  a 
very  pale  face,  a  quick  pulse,  hemorrhage,  emaciation,  and  a  cough, 
followed  by  profuse  purulent  sputa  of  a  greenish  or  brown  color. 
But  nearly  all  these  symptoms  happen  also  in  phthisis.  What  is 
characteristic  of  gangrene  is  the  extreme  fetor  of  the  expectoration 
and  of  the  breath.  The  sickening  odor  is  not  perceived  during  each 
act  of  breathing,  but  mainly  after  coughing,  and,  as  it  were,  in  jets. 
It  is  the  symptom  by  which,  especially  if  taken  in  connection  with  the 

^  See  an  elaborate  paper  by  Hutinel  and  Proust,  Arch.  Gen.  de  Med.,  Nov. 
1882. 


DISEASES  OF  THE  LUNGS.  329 

signs  of  breaking  up  of  the  pulmonary  tissue  and  the  sputum,  gan- 
grene is  with  certainty  recognized.  The  cavity  is  found  in  only  one 
lung,  and  generally  at  its  lower  part.  This  is  of  aid  in  discriminating 
between  phthisis  and  gangrene  ;  but  it  does  not  distinguish  between  a 
gangrenous  excavation  and  a  simple  abscess  of  the  lung.  The  only 
positive  proof  of  gangrene  of  the  lung  is,  as  just  stated,  that  the  signs 
of  breaking  down  of  the  pulmonary  tissue  are  accompanied  by  a  dis- 
gusting and  more  or  less  persistent  fetor  of  the  expectoration  and  of 
the  breath ;  sometimes  a  sickening,  faintly  sweetish  smell,  sometimes 
fecal,  oftener  that  of  putrescence.  I  say  persistent,  because  local 
gangrene,  on  a  small  scale,  occurring  around  tubercular  cavities  or  in 
bronchitis,  may  give  rise  to  temporary  extreme  fetor  of  the  breath. 
But  it  is  only  temporary,  and  therefore  not  liable  to  lead  to  fallacious 
inferences.  The  expectoration  may  be  fetid  in  cases  of  bronchial 
dilatation  or  of  abscess  of  the  lung,  but  is  never  brownish,  as  is  not 
uncommon  in  gangrene ;  and  neither  it  nor  the  breath  has  the  pecu- 
liar gangrenous  odor.  In  rare  instances  pleurisy  with  fetid  effusion 
may  occasion  a  fecal  smell  of  the  expectoration  and  breath,  which  is 
gradually  lost.^  The  fetid  sputum  of  fetid  bronchitis  is  not  associated 
with  any  signs  of  breaking  down  of  the  lung. 

Yet  in  considering  the  diagnosis  regarding  bronchial  dilatation  we 
must  not  overlook  the  fact  that,  as  Dittrich  and'Traube^  have  shown, 
this  bears  a  marked  relation  to  gangrene.  Decomposition  takes  place 
in  the  secretions  retained  in  the  bronchial  dilatation,  and  ulceration 
of  the  coats  may  ensue,  leading  to  a  gangrenous  process  in  the  sur- 
rounding tissue.  Now,  as  just  mentioned,  the  sputum  even  in  bron- 
chial dilatation  may  become  fetid.  As,  moreover,  it,  like  gangrenous 
sputum,  may  present  a  dirty  greenish-yellow  color,  and  separate  on 
standing  into  three  distinct  strata,  of  which  the  uppermost  is  frothy 
though  dense,  the  second  serous,  and  the  third  dense,  containing  pure 
pus  and  detritus  ;  as,  further,  we  meet  in  both  affections  with  little 
solid  masses  of  particularly  offensive  odor  full  of  fat  and  fine  needle- 
shaped  crystals  of  margaric  acid, — we  may  have  to  depend,  for  a  dif- 
ferential diagnosis,  on  finding  with  the  microscope  pigment  grains  and 
masses  of  elastic  tissue. 

Pulmonary  Actinomycosis. — This  rare  disease  resembles  tubercular 
disease  of  the  lung  in  presenting  cough,  fever,  wasting,  and  a  muco- 
purulent expectoration.  The  attending  fever  is  of  irregular  type, 
sometimes  like  that  of  typhoid  fever,  more  generally  like  hectic  fever. 


^  As  in  the  case  reported  by  William  Moore  (Dubl.  Quart.  Journ.,  May,  1865). 
^  Gesammelte  Abhandlungen. 

21 


330  MEDICAL   DIAGNOSIS. 

The  physical  signs  are  mostly  those  of  tubercular  deposit.  The 
absolutely  distinctive  feature  is  finding  the  ray  fungus  in  the  sputum. 
Besides  the  lungs,  other  parts  of  the  body  may  be  involved,  such  as 
the  jaw,  the  alimentary  canal,  and  the  subcutaneous  tissues. 

With  reference  to  other  affections  which  are  sometimes  mistaken 
for  pulmonary  tuberculosis,  owing  to  emaciation  and  an  attending 
cough,  such  as  mtermittent  fever,  anasmia,  dyspepsia,  chronic  diar- 
rhoea, chronic  laryngitis,  and  chronic  pharyngitis,  the  physical  signs 
are  different,  and  an  examination  for  tubercle  bacilli  is  conclusive. 

In  the  remarks  on  the  diagnosis  of  pulmonary  consumption,  the 
complaint  has  been  assumed  to  be  progressive  ;  in  rare  instances  it 
retrogrades.  The  signs  by  which  such  retrogression  can  be  discov- 
ered are  not  very  fixed.  In  those  cases  in  which  many  tubercles 
undergo  a  cretaceous  transformation,  calcareous  particles  are  coughed 
up ;  the  signs  of  softening  cease  ;  fibroid  changes  take  place  m  the 
affected  lung  ;  the  apex  flattens  ;  and  a  feeble  murmur  with  prolonged 
expiration,  or  a  harsh  respiration  with  slight  dulness  on  percussion, 
is  all  that  remains  to  indicate  that  tubercular  disease  has  existed. 
The  cough  stops,  and  flesh  and  strength  return. 

We  meet  occasionally  with  instances  in  which  the  physical  signs 
of  an  infiltration  into  the  lung-tissue  depart  with  tolerable  rapidity. 
They  occur  m  those  who  have  a  decidedly  scrofulous  aspect,  en- 
largement of  the  glands  of  the  neck,  or  a  scrofulous  inflammation  of 
the  eyes.  In  accordance  with  the  acknowledged  identity  of  scrofula 
and  tubercle,  we  are  forced  to  admit  that  the  disease  in  the  lungs  is 
tubercular.  Yet  the  connection  with  the  enlarged  lymphatics ;  the 
circumstance  that  the  diminution  in  size  of  the  glands  is  often  fol- 
lowed by  increased  pulmonary  deposits  ;  that  these  depositions  are 
very  beneficially  influenced  by  treatment ;  that  they  disappear  some- 
times altogether,  or  only  reappear  months  afterwards  ;  that  hemor- 
rhage is  not  among  the  symptoms, — all  make  it  a  cjuestion  whether 
there  be  not  a  scrofulous  disease  of  the  lung  independent  of  a  tubercu- 
lar, one  pursuing  more  the  course  of  an  external  scrofulous  disease, 
one,  moreover,  which  presents  a  much  more  favorable  prognosis 
than  ordinary  consumption.  Among  scrofulous  children  cases  like 
these  mentioned  are  not  uncommon.  The  disorder  certainly  differs 
from  the  ordinary  forms  of  pulmonary  tuberculosis,  and  it  is  not 
bronchial  phthisis.  It  does  not  present  the  paroxysmal  cough,  the 
signs  of  pressure  on  the  trachea  or  the  large  bronchi,  and  the  dufl 
sound  on  percussion  between  the  scapulae,  which  are  the  common 
accompaniments  of  enlarged  and  tuberculous  bronchial  glands.  In- 
deed, the  bronchial  glands  are  not  of  necessity  involved. 


DISEASES  OF  THE   LUNGS.  331 

The  Acute  Affections  of  the  Lungs  accompanied  by  Dulness  on 

Percussion. 

The  acute  diseases  of  the  lungs  are  bronchitis,  pneumonia,  pleu- 
risy, and  acute  tuberculosis.  They  have  some  signs  and  many  symp- 
toms in  common.  They  all  present  fever ;  they  are  all  associated 
with  more  or  less  dyspnoea  and  thoracic  pain ;  they  all  occasion  a 
cough.  The  symptoms  and  signs  of  acute  bronchitis  have  been  dis- 
cussed. It  has  been  pointed  out  that  the  v^ant  of  intensity  of  the 
fever,  and  particularly  the  unimpaired  resonance  on  percussion, 
separate  bronchial  inflammation  from  all  affections  that  occasion  con- 
solidation or  compression  of  the  lung-tissue.  We  may  then  proceed 
to  examine  the  other  acute  pulmonary  affections. 

Acute  Tuberculosis. — When  tuberculosis  runs  its  course  rap- 
idly, it  is  known  as  acute  tuberculosis,  acute  phthisis,  or  gallopmg 
consumption.  This  formidable  complaint  is  met  with  at  the  close  of 
other  diseases,  especially  of  fevers  ;  but  exposure,  toil,  and  anxiety 
are  also  among  its  predisposing  causes. 

The  disorder  often  begins  with  a  severe  chill  :  fever  follows  ;  at 
first  like  any  fever  with  anorexia,  quickened  pulse,  and  elevated  tem- 
perature, but  soon  accompanied  by  exhausting  night-sweats  and 
rapid  emaciation,  which,  in  connection  with  the  intense  restlessness 
and  prostration,  the  high  temperature,  and  the  supervention  of 
delirium,  may  cause  the  febrile  disturbance  closely  to  resemble 
typhoid  fever.  The  symptoms  that  point  to  the  thoracic  malady  are 
the  accelerated  breathing,  the  cough,  the  copious  expectoration,  the 
pain  in  the  chest,  and  the  spitting  up  of  florid  blood. 

The  physical  signs  are  not  always  the  same.  If  the  tubercles  be 
scattered  through  the  lungs,  no  signs  are  perceived  but  those  of 
diffused  acute  bronchitis  ;  indeed,  the  sputum  is  of  the  same  kind,  and 
tubercle  bacilli  are  not  found,^  or  are  infrequent.  More  commonly  the 
signs  are  like  those  of  chronic  pulmonary  tuberculosis,  and  associ- 
ated with  the  fever  and  prostration  we  find  the  percussion  dulness  of 
a  deposit,  or  the  evidences  of  the  destruction  of  the  pulmonary  tissue, 
furnished  by  coarse  moist  rales,  and  cavernous  breathing.  Tubercle 
bacilli  are  then  usual. 

When  the  malady  assumes  the  form  resembling  chronic  pulmo- 
nary consumption,  the  diagnosis  from  bronchitis  is  not  perplexing ; 
but  when  its  phenomena  are  similar  to  those  of  acute  bronchitis, 
the  recognition  of  the  tubercular  affection  may  be  impossible.     This 


^  Von  Jacksch,  Klinische  Diagnostik. 


332  MEDICAL  DIAGNOSIS. 

remark  applies  particularly  to  the  distinction  of  the  miliary  form, 
acute  miliary  tuberculosis,  from  bronchitis  of  the  finer  tubes.  From 
this  the  diagnosis  can  be  effected  only  by  taking  into  account  that 
repeated  chills,  rapid  emaciation,  and  profuse  sweats  are  wanting  in 
the  bronchial  affection ;  that  the  temperature  is  not  so  high,  nor  so 
irregular ;  that  the  rales  are  more  abundant  and  more  perceptible  at 
the  lower  part  of  the  chest ;  and  that,  perhaps,  the  breathing  is  not 
so  hurried  or  so  difficult.  Moreover,  with  the  intense  dyspnoea  there 
are  generally  frequent  and  violent  fits  of  coughing,  and  marked  chest 
pains,  in  the  acute  tubercular  malady.  Yet  none  of  these  signs  are 
convincing  proofs.  The  presence  of  dulness  on  percussion,  or  the 
sinking  in  at  the  upper  part  of  the  chest,  the  occurrence  of  hemor- 
rhage, the  finding  of  the  tubercle  bacillus,  if  present,  the  eruption  of 
miliary  tubercles  in  other  organs,  and  the  longer  duration  of  the  case 
are  alone  conclusive  evidence  in  favor  of  the  acute  tubercular  disease. 
Hemorrhage  is,  however,  by  no  means  so  constant  in  the  acute  as  in 
the  chronic  form  of  the  affection. 

Much  the  same  symptoms  will  enable  us  to  distinguish  between 
acute  tuberculosis  of  the  miliary  form  and  broncho-pneumonia,  except 
that  we  can  draw  no  inference  from  the  dulness  on  percussion,  further 
than  that  its  early  occurrence,  with  the  bronchial  symptoms,  points  to 
the  pneumonic  malady  ;  its  later  occurrence,  after  the  grave  symptoms, 
to  the  tubercular. 

When  the  dulness  on  percussion  is  marked,  acute  tuberculosis 
may  be  mistaken  for  ordinary  pneumonia.  But  the  signs  of  deposit 
and  of  softening  in  both  lungs,  and  the  seat  of  the  lesions  at  the 
apices,  show  differences  from  a  disease  which,  in  the  large  majority 
of  instances,  is  one-sided  and  at  the  lower  part  of  the  lung,  which 
exhibits  a  characteristic  sputum,  and  in  which  breaking  up  of  the 
pulmonary  tissue  is  so  rare. 

Yet  there  are  cases  of  acute  phthisis  that  display  symptoms  and 
signs  very  puzzling,  and  strongly  simulating  those  of  pneumonia. 

A  person  in  perfectly  good  health  is  seized,  after  exposure,  with 
cough  and  fever.  They  are  accompanied  by  dyspnoea,  and  soon  we 
find  signs  of  consolidation  of  the  lower  lobe,  or  of  one  lung.  The 
dulness  on  percussion  does  not  disappear  under  treatment;  and  a 
hollow,  blowing  respiration  and  gurgling,  usually  first  perceptible  at 
the  angle  of  the  scapula,  gradually  appear,  and  indicate  the  formation 
of  a  cavity.  Emaciation,  which  began  from  the  onset,  progresses 
more  rapidly,  and  goes  hand  in  hand  with  extreme  prostration  and 
profuse  perspirations.  The  sputa  are  copious  and  purulent,  but  at  no 
time  mixed  with  blood.     The  other  lung  is  normal.     The  case  remains 


DISEASES  OF  THE  LUNGS.  333 

in  this  condition  for  several  weeks,  the  patient  temporarily  improving 
under  stimulants,  yet,  on  the  whole,  growing  weaker  and  tormented 
with  fever  of  very  irregular  type.  A  slight  roughening  of  the  inspira- 
tory murmur,  or  dry  rales  at  the  apex  of  the  unatfected  lung,  attract 
attention,  and  dulness  on  percussion  and  the  signs  of  deposition 
become  there  more  and  more  manifest.  A  post-mortem  examination 
exhibits  nearly  the  whole  of  one  lung  converted  into  a  uniform  yel- 
lowish or  grayish  mass  of  tubercle,  and  containing  one  or  several 
large  excavations ;  not  a  vestige  of  healthy  lung-structure  is  to  be 
seen.  Scattered  tubercles  are  found  in  the  other  lung,  and  mainly  at 
its  apex. 

The  case  just  described  is  one  of  a  group  which  every  physician 
has  met  with.  The  beginning  of  the  case  as  one  of  pneumonia  or 
broncho-pneumonia,  the  persistent  consolidation,  the  occurrence  of 
rales  and  of  subsequent  dulness  on  percussion  at  the  upper  part  of  the 
previously  unaffected  side,  the  continuance  of  the  disease,  and  the 
prostration  and  sweats  which  accompany  it,  permit  us  to  foretell  its 
nature  and  the  probable  fatal  termination,  even  without  the  positive 
evidence  of  tubercle  bacilli  in  the  sputum. 

Such  cases  were  not  long  since  classed  as  acute  pneumonic  phthisis, 
and  looked  upon  as  inflammatory,  with  resulting  caseous  infiltration, 
and  its  disintegration.  With  our  present  knowledge  of  the  bacillar 
origin  of  consumption,  they  are  explained  by  supposing  that  the 
tubercle  bacilli  have  fastened  readily  on  the  altered  lung,  or  that  they 
have  occasioned  the  attending  inflammatory  process. 

Acute  phthisis  may  simulate  other  affections  besides  those  of  the 
chest.  It  has  at  times  the  delirium  and  prostration,  the  dry  tongue, 
and  the  bronchial  rales  of  typhoid  fever.  The  diarrhoea  and  the 
abdominal  symptoms  are,  however,  wanting.  Yet  simultaneous  depo- 
sition of  tubercles  in  the  intestine  may  cause  these ;  and  in  this  case 
the  chief  mark  of  diS'erence  from  typhoid  fever  is  the  absence  of  an 
eruption.  Besides,  the  Widal  test  is  negative,  and  the  thermometric 
record  shows  great  and  sudden  variations,  to  the  extent,  perhaps,  of 
six  or  seven  degrees,  bearing  no  relation  to  the  number  of  respira- 
tions or  to  the  beats  of  the  pulse.  In  the  blood  there  is  great  de- 
crease in  the  leucocytes,  with  a  relative  increase  in  the  polynuclear 
cells.  As  there  is  also  a  decided  diminution  of  the  leucocytes  in 
typhoid  fever,  but  little  importance  can  be  attached  to  the  blood- 
examination  in  the  diagnosis  between  typhoid  fever  and  acute  tuber- 
culosis.^    Acute   tuberculosis   lacks  the   eye-phenomena,  the   gastric 

'  Warthin,  Medical  News,  Jan.  1896. 


334  MEDICAL  DIAGNOSIS. 

disturbance,  the  rigid  muscles,  the  convulsions,  of  meningitis;  else 
the  active  delirium  it  occasionally  produces  might  be  attributed  to 
inflammation  of  the  membranes  of  the  brain. 

Acute  tuberculosis  sometimes  progresses  with  extreme  rapidity. 
I  have  seen  a  case  terminate  in  thii^teen  days.  It  is  almost  invariably 
fatal.  Yet  it  has  its  periods  of  deceptive  improvement:  the  disease 
may  proceed  speedily  towards  softening,  and  then  remain  for  a  time 
stationary.  In  some  instances  the  termmation  is  the  result  of  compli- 
cations, as  of  tubercular  meningitis,  or  of  erysipelas  of  the  throat  and 
the  bronchial  tubes. 

Acute  Pneumonia. — Inflammation  of  the  lung,  or  "  croupous 
pneimionia,"  is,  in  its  symptoms,  the  type  of  the  acute  pulmonary 
affections.  The  hot,  dry  skin,  the  flushed  face,  the  quickened  pulse, 
the  extremely  rapid  breathing,  the  thoracic  pain,  the  cough,  and  the 
peculiar  expectoration,  point  out  at  once  the  acute  nature  of  the 
attack  and  the  organ  that  is  disturbed.  Beginning  commonly  with  a 
cli£l,  or  with  flushes  of  heat,  the  disease  progresses  with  the  symp- 
toms indicated. 

The  expectoration  is  characteristic.  It  consists  at  first  of  a  glairy 
mucus :  soon  it  becomes  more  viscid,  and  acc|uires  the  appearance 
dependent  upon  the  admixture  of  blood  Avith  the  mucus  and  exuda- 
tion matter,  to  wliich  the  term  rusty-colored  has  been  given.  Tliis 
rusty  sputum  is  pathognomonic  of  pneumonia;  yet  cases  run  their 
course  without  it.  The  expectoration  is  sometimes  like  prune-juice, 
or  it  is  purulent.  Both  augur  badly  :  both  indicate  that  destruction  of 
the  lung-tissue  has  begun. 

The  shortness,  or  increased  frequency,  of  breathing  is  another 
marked  symptom.  The  patient  draAvs  from  forty  to  eighty  breaths  a 
minute ;  but  the  pulse,  although  rapid,  does  not  quicken  in  propor- 
tion. Pneumonia,  therefore,  forms  an  exception  to  the  rule  that  with 
greater  frequency  of  breathing  the  pulse  rises.  This  perverted  pulse 
respiration-ratio  may  be  made  an  important  element  in  the  diagnosis. 
The  febrile  symptoms  are  ordinarily  severe  ;  still,  they  are  not  asso- 
ciated with  decided  cerebral  disturbance.  Headache  is  common ; 
delirium  is  rare,  and,  when  it  occurs,  is  indicative  of  danger.  In 
drunkards  it  may  take  the  form  of  delirium  tremens.  The  flush  on 
the  cheek  is  so  decided  that  by  this  and  the  hurried  breathing  alone 
the  disease  may  often  be  recognized.  The  flush  is  generally  most 
obvious  when  the  inflammation  affects  the  apex  of  the  lung.  Herpes 
is  also  a  common  symptom. 

The  temperature  rises  abruptly,  and  on  the  first  or  second  day  at- 
tains 103°  to  105°  F.     In  children  and  in  robust  adults  it  is  specially 


DISEASES  OF  THE   LUNGS. 


335 


high.  It  shows  httle  change,  except  an  evenhig  exacerbation  and  a 
marked  morning  remission  of  from  1.5°  to  2.5°  for  five  to  nine  days. 
Between  these  days,  sometimes  on  the  fifth,  generahy  on  the  seventh 
day,  it  falls  abruptly,  and  a  true  crisis  occurs.  The  temperature  may 
sink  to  the  norm,  or  even  below  it,  and  then  another,  though  not 
marked,  rise  take  place.  At  times  there  happens  on  the  fifth  day  a 
partial  but  decided  drop,  soon  again  followed  by  ascending  tempera- 
ture.    This  pseudo-crisis  is  apt  to  occur  in  cases  that  become  pro- 


FiCx.   35. 

^i  "T 

"  E 

,.|l«|s,j»t.t»|e.it«li»E"ili'|£«|l-£-|t"S«..|t-;E-il.s.Js.[,i.tME«t 

BOWELS 

NUMBER  OF   MOVEMENTS 

'     '      -        '  -          J  J  T     T     /  1    i        TL     -  TL'Z' 

URINE,    DAILY   AMOUNT 

i               !       1                      1       1       1       1 

-^      

+  s> 

a  ' 

lli<-[<-  i!  <  I  <  ^  *  al*'  *  <.^*  li^-  ^u  <■  *  ^  ^ '  il.  ^l^  ^  !l|i  ^1  %1  IIS.  <-]i  lit  in  ^  ^  '•  ^^  i  I 

i~~N 

'315 

5   L   '  •    '           -                     : 

101"  -T- 

J — '— 

i--L_J_^„_  —  jp-p-i L-j LJ i 

j] 

±         ^  :  3  =  :p  =  =   ==         :::=   :   ::     :   :     -^       :  ± 



-^— ' ^ ^ '. Kt^-H\—\- — i- — ^r/--P-^H- 

, 

— ' --i "•-'— r/^^"^?*i \^< ^^    r 

J L_ 

_^ 

n — ^^ L  i  it?=  J'__fc?^^_i_     !t__x: ?- 

— ,-      -^ 

~ — 

-±  — T^:""           =nni±  +  +  ir>'  — --y  — =r±  — +  T 

—*■       __ 

—  -i- 

DAY  OF  DISEASE                1 

2    3 

t                  5                  6                  7            8            9           10         11          15                13          U|16  16 

PULSE 

96 

96    96 
9S    96 

96     9 
100   9 

8    84    92    92    92  108  108  96    96    92    90    88    92    88    86    81    80    86    76           90    84    64    86  74    72    72 
2  84    ?4  90  104108  100  90    92    92    82    86    82    88    30    84    73    80    88    88    90    90            76    72    72 

RESPfRATlON 

28 

30    3 

2    23    30    32    30    36    32    28    32     >6    22    26    18     20    22    22    ^0 1 20    18            20    20    20    20     20    13     18 
2    23    34    33    30    96    30    30    30    24    26    24    20    20    20    20    20    18    20    20    20    20            22    20    18 

DATE,     APRfL                  5 

6 

7 

i  8                  9                 10                11          12          13          U         15         16                17|18   19  20 

Temperature  chart  in  pneumonia.  The  observation  was  begun  on  the  first  day  of  the  disease. 
The  crisis  commenced  towards  the  end  of  the  fifth  day,  and  continued  through  the  sixth  to  the 
seventh,  mth  a  secondary  rise  on  the  sixth.  The  chart  is  typical,  except  that  the  fever  tem- 
perature throughout  was  about  a  degree  lower  than  is  usual.  There  was  a  slight  right-sided 
pleurisy,  but  no  attending  bronchitis. 


longed.  It  is,  too,  in  this  class  of  cases  with  slow  resolution  that  a 
gradual  termination  of  the  fever  is  often  observed.  Sometmies  the 
course  of  the  fever  is  marked  by.  sudden  elevations  and  striking  remis- 
sions. This  is  more  common  in  double  than  in  single  pneumonia, 
and  seems  to  correspond  with  fresh  invasions  of  lung-tissue. 

The  urine  is  high-colored,  and  that  of  fever.  Nitrate  of  silver 
does  not  precipitate  its  chlorides.  They  commonly  disappear  during 
consolidation  of  the  lung,  and  their  reappearance  shadows  forth  re- 
turning health.     The  vanishing  of  tlie  chlorides  from  the  urine  hap- 


336  MEDICAL  DIAGNOSIS. 

pens  also  in  other  acute   affections ;   but  in  pneumonia  it  is  most 
absolute. 

Pneumonia  often  exists  in  combination  with  other  maladies.  We 
find  it  in  association  with  meningitis,  and  we  must  therefore  always 
examine  any  cerebral  symptoms  with  care ;  we  note  it  in  connection 
with  endocarditis,  which  may  coexist  with  meningitis  ;  while  its  asso- 
ciation with  pleurisy  is  so  common  that  this  can  be  hardly  looked 
upon  as  a  complication.  Among  the  rarer  symptoms  are  jaundice, 
parotitis,  croupous  colitis,  milk  leg,  and  transitory  aphasia,  appearing 
on  the  second  or  the  third  day. 

The  physical  signs  vary  with  the  effects  of  the  inflammation.  In 
the  first  stage,  or  that  of  engorgement  and  beginning  exudation  in  the 
air-cells,  there  is  only  a  slight  impairment  of  the  normal  resonance 
on  percussion.  The  vesicular  murmur  is  at  first  somewhat  altered ; 
it  may  be  feebler  or  harsher.  But  soon  are  heard  with  each  act  of 
inspiration,  and  limited  to  the  inspiration,  numerous  rapidly  evolved, 
very  fine,  crackling  sounds,  the  "  crepitant"  or  vesicular  rales. 

As  the  exudation  becomes  firmer,  and  the  tissue  of  the  lung  solidi- 
fies by  occlusion  of  the  air-cells,  all  the  signs  of  complete  consolida- 
tion are  discerned.  We  find  in  this  stage  of  red  hepatization  decided 
dulness  on  percussion,  unchanged  by  full  inspiration ;  blowing  respi- 
ration in  its  purity,  high-pitched  and  tubular-sounding ;  bronchophony ; 
and  increased  vocal  fremitus.  Rales  from  the  accompanying  bron- 
chitis are  heard  with  extreme  distinctness  through  the  solidified  tissue ; 
so  are  the  sounds  of  the  heart.  A  crepitant  rale  is  still  here  and 
there  perceptLl3le,  or  the  ear  catches  a  pleural  friction-sound. 

When  the  exudation  is  reabsorbed  or  expectorated,  the  signs  of 
consohdation  become  less  and  less  perfect.  A  vesiculo-bronchial  suc- 
ceeds to  the  bronchial  breathing.  The  dulness  on  percussion  lessens  ; 
crepitant  rales — not,  however,  so  fine  as  at  the  onset  of  the  affection, 
and  mixed  with  larger  moist  rales — return  ;  the  cough  increases  ;  the 
expectoration  becomes  more  copious,  loses  its  tenacity  and  rusty  color  ; 
the  dyspnoea  diminishes, — all  phenomena  indicative  of  the  breaking  up 
of  the  exudation,  and  of  the  return  of  air  into  the  vesicles.  If,  instead, 
the  exudation  be  converted  extensively  into  pus,  and  the  lungs  soften, 
the  physical  signs  are  the  same  as  in  the  second  stage.  The  rarity  of 
excavations  of  sufficient  size  explains  why  gurgling  and  the  signs  of  a 
cavity  are  not  perceived.  '  We  suspect  the  mischief  that  is  going  on 
within  the  chest  from  the  protracted  dyspnoea,  the  increasing  rapidity 
of  pulse,  the  purulent  or  brownish  sputa,  the  pinched  features,  the 
dry  tongue,  and  the  mental  wandering.  Recovery  may  take  place 
even  then.     This  third  stage  is  indeed  not  so  much  an  abrupt,  sud- 


DISEASES   OF  THE  LUNGS. 


337 


denly  established  process,  as  it  is  ttie  extension  and  greater  diffusion 
of  a  state  that  may  be  found  in  portions  of  tlie  lung  which  to  the  eye 
have  still  all  the  appearance  of  red  hepatization.  It  is  often  impossi- 
ble to  determine  that  the  stage  of  purulent  infiltration  or  gray  hepati- 


FiG.  36. 


Percussion  dulness 

Bronchial  breathing / 

Bronchial  voice , 

/ 
Increased  fremitus 


Diagram  illustrative  of  perfect  pulmonary  consolidation,  such  as  happens  in  the  second  stage  of 

pneumonia. 

zation  has  arrived ;  and  death  may  take  place  long  before  the  lung 
presents  the  condition  which  pathologists  term  gray  hepatization.  We 
may  suspect,  from  the  symptoms,  that  the  pulmonary  tissue  is  seri- 
ously damaged.  But  we  can  never  know  it,  unless  we  find  the  physi- 
cal signs  of  extensive  softening ;  and  this  we  very  rarely  do.  True 
abscess  of  the  lung  is  extremely  infrequent. 

The   morbid   phenomena,  physical   signs   and   symptoms  of  the 
malady  correspond,  then,  usually  in  this  manner : 


Pneumonia. 
I.  Stage    of    engorgement     Crepitant  rale  ;  slight  per- 
and   beginning  exuda-         cussion  dulness. 
tion. 


II.  Stage  of  solidification 
of  lung-tissue  (red  hep- 
atization). 


Percussion  dulness  ;  bron- 
chial respiration  ;  bron- 
chophony ;  often  a  pleu- 
ral friction-sound. 


Cough ;  beginning  dysp- 
noea and  rapidly  devel- 
oped fever. 

Rusty  -  colored  sputum  ; 
dyspnoea  ;  cough  ;  tem- 
perature generally  above 
103°,  with  decided  even- 
ing exacerbations  and 
morning  remissions. 


338  MEDICAL   DIAGONSIS. 

III.   Stage     of      softening     The   same    physical    signs     Chills,    prostration,    puru- 

(gray  hepatization).  as  in  the  second  stage  ;         lent   or   brownish    spu- 

unless    large    abscesses         turn ;      generally     high 

have  formed.  temperature,     104°     to 

105°,  or  upward. 

Here  is  a  disease  which  presents  such  striking  symptoms  and 
signs  in  nearly  all  its  phases,  in  which  the  sputa  are  so  peculiar,  the 
physical  signs  so  distinct,  that  error  is  difficult.  It  becomes  still  more 
so,  if  a  few  of  the  pathological  peculiarities  of  pneumonia  be  borne  in 
mind :  the  fact  that  it  is  rarely  double ;  that  it  comparatively  seldom 
affects  the  upper  lobe  of  the  lung,  and  that  it  is  generally  accompanied 
by  the  signs  of  pleurisy  or  of  bronchitis.  In  some  instances  sudden 
disturbance  of  the  circulation  takes  place  with  the  rapid  development 
of  cyanosis.  These  symptoms  bespeak  a  heart-clot,  or  an  acute  dila- 
tation of  the  right  side  of  the  heart.  Delayed  resolution  is  most  often 
encountered  in  apex  pneumonia. 

Let  us  now  contrast  pneumonia  with  the  various  diseases  of  the 
lungs  with  which  it  may  be  confounded.  In  its  first  stage,  on  account 
of  similar  signs,  the  acute  inflammatory  disorder  is  sometimes  mis- 
taken for  oedema  of  the  lung,  or  for  the  pulmonary  engorgement  in 
some  fevers,  or  for  other  kinds  of  congestion  of  the  lungs,  and  still 
more  frequently  these  morbid  states  are  mistaken  for  it. 

Pulmonary  (Edema. — This  consists  in  the  transudation  of  serum 
into  the  air-vesicles.  It  may  be  acute,  the  result  of  sudden  conges- 
tion, such  as  that  following  injuries  of  the  brain  or  irritation  of  the 
par  vagum ;  or  it  may  arise  at  the  termination  of  acute  affections  of 
the  lungs.  It  is  more  usually,  however,  chronic,  and  is  seen  as  a 
dropsy  of  the  air-cells,  associated  with  dropsies  elsewhere,  and  in 
connection  with  organic  disease  of  the  liver,  heart,  or  kidneys.  The 
characteristic  manifestations  of  oedema — be  it  acute  or  chronic — are 
embarrassed  breathing,  expectoration  of  frothy  serum,  and  crepitating 
and  fme  bubbling  sounds  diffused  over  both  lungs,  and  dependent 
upon  the  fluid  in  the  air-cells  and  small  bronchial  tubes.  It  presents, 
thus,  many  points  of  similarity  to  the  first  stage  of  acute  pneumonia. 
The  dyspnoea,  the  crepitation  in  the  lung,  may  well  mislead ;  but  we 
cannot  err,  if  the  frothy  sputum,  the  general  distribution  of  the  rales, 
their  somewhat  coarser  character,  the  bluish  lip,  the  noisy  breathing, 
and  the  absence  of  fever  be  taken  into  account.  In  acute  oedema 
these  signs  are  but  the  precursors  of  death.  In  chronic  oedema  the 
rales  are  persistent,  and  so  is  the  great  difficulty  in  respiration. 

Pulmonary  Engorgement  in  Fevers. — In  fever  of  low  type  a  crepi- 
tant rale,  which  might  be  supposed  to  be  a  proof  of  beginning  inflam- 


DISEASES  OF  THE  LUNGS.  339 

mation  of  the  lung,  is  often  heard  at  the  back  part  of  the  chest.  The 
sound  is  the  consequence  of  pulmonary  congestion,  with  probably 
slight  effusion  into  the  finest  bronchial  tubes  and  air-vesicles.  It  is 
perceived  over  both  lungs  ;  and  this,  taken  in  connection  with  the 
history  of  the  case,  with  the  absence  of  decided  shortness  of  breath, 
and  with  the  rale  not  being  followed  by  dulness  on  percussion  and 
blowing  respiration,  shows  that  it  is  not  dependent  on  inflammation 
of  the  pulmonary  tissue. 

Pulmonary  Congestion. — Besides  the  lung  congestion  just  referred 
to  as  occurring  in  fevers,  we  have  other  causes  producing  a  marked 
congestion,  or  "  hypostatic  pneumonia."  We  find  it  in  enfeebled 
hearts  and  in  mitral  and  tricuspid  disease,  in  those  whose  blood  is 
impoverished  and  who  are  for  any  length  of  time  bedridden,  in  in- 
stances of  acute  rheumatism,  and  due  to  the  pressure  of  tumors.  In 
the  dependent  portions  of  the  lungs  the  manifestations  of  congestion 
show  themselves  first ;  they  are,  besides  the  signs  of  impeded  circula- 
tion and  of  deficient  aeration  of  blood,  slight  expectoration,  scarcely 
any  fever,  varying  shortness  of  breath,  somewhat  impaired  resonance 
on  percussion  at  the  lower  part  of  the  chest, — generally  more  over  the 
right  than  over  the  left  lung, — feebleness  of  respiratory  murmur,  and 
a  few  fine  and  coarse  moist  rales.  The  sputum  contains  numerous 
epithelial  cells,  and  blood  pigment  in  various  stages  of  change. 

The  congestion  in  all  the  instances  mentioned  is  passive,  and 
either  hypostatic  or  mechanical.  An  active  congestion  of  the  lungs 
is  a  rare  condition,  though  it  may  come  on  after  strenuous  exertion, 
during  mountain  climbing,  or  as  subsequent  to  extreme  heat  or  cold. 
The  physical  signs  are  the  same  as  those  of  passive  congestion ; 
the  sputum  is  apt  to  contain  more  blood.  There  is  little,  if  any 
fever ;  and  the  history  of  the  case,  the  stationary  character  of  the 
physical  signs,  and  their  double-sidedness,  distinguish  the  congestive 
disorder  from  pneumonia. 

In  its  second  stage,  owing  to  the  cough  and  dyspnoea,  and  in  part, 
also,  to  some  similarity  in  the  physical  signs,  acute  pneumonia  may  be 
confounded  with  pulmonary  apoplexy,  acute  pleurisy,  acute  phthisis, 
and  acute  bronchitis. 

Pulmonary  Apoplexy. — An  effusion  of  blood  into  the  texture  of 
the  lung  is  generally,  although  by  no  means  invariably,  accompanied 
by  external  hemorrhage  and  by  great  difficulty  of  breathing.  Over  the 
effused  blood  there  is  dulness  on  percussion,  and  the  ear  hears  an 
enfeebled  or  bronchial  respiration.  Around  the  seat  of  the  mishap  it 
encounters  moist  rales.  Now,  here  are  signs  bearing  some  resem- 
blance to  those  of  pneumonia.     But  we  miss  from  among  them  the 


340  MEDICAL  DIAGNOSIS. 

decided  fever.  We  note,  on  the  other  hand,  not  blood  intimately 
mixed  with  the  expectoration,  but  pure  blood,  florid  or  sooty-looking, 
almost  devoid  of  air,  not  in  large  amount,  at  times  surrounded  with 
muco-purulent  matter,  and  ordinarily  voided  for  a  number  of  days. 
On  close  scrutiny  a  grave  disease  of  the  heart  is  generally  detected. 
Then  we  frequently  find  the  branch  of  the  pulmonary  artery  leading 
to  the  infarcted  part  plugged  by  an  embolus,  which  has  been  formed 
in  the  right  cavities  of  the  heart  or  been  washed  in  through  the 
general  venous  system,  and  commonly  affects  the  right  lung.  Again, 
we  have  more  pain  than  in  pneumonia,  and  the  dyspnoea  is  different. 
In  pneumonia  it  augments  up  to  the  height  of  the  malady.  In  pul- 
monary apoplexy  it  is  greatest,  and  it  is  very  great,  when  the  blood  is 
extravasated ;  after  that  it  declines.  Yet  the  two  affections  often  co- 
exist. The  closure  of  the  vessel  produces  a  pneumonia  from  em- 
bolism, or  the  blood  acts  as  a  foreign  body,  and  around  it  is  lighted 
up  an  inflammation  of  the  lung-structure,  which  is  apt  to  have  its  seat 
in  the  posterior  part  of  the  lower  lobe  of  the  right  lung ;  further,  the 
inflammation  may  be  the  starting-point  of  caseous  degeneration ;  or 
sloughing  or  gangrene  may  result. 

Pneumonia  from  embolism  may  be  also  caused  by  a  pysemic  con- 
dition, and  the  clots  may  have  their  origin  in  bedsores,  in  ulcers,  and 
in  various  forms  of  suppuration.  The  plugs  are  saturated  with  ichor, 
and  metastatic  abscesses  supervene.  The  symptoms  are  the  same, 
and  we  can  make  a  diagnosis  only  by  the  history ;  there  are  the  same 
circumscribed  spots  of  consolidation,  and  the  same  kind  of  pain,  which 
is  also  often  found  to  be  associated  with  a  localized  pleurisy,  some- 
times followed  by  effusion. 

Pulmonary  apoplexy  is  met  with  in  connection  with  other  than 
thoracic  affections.  Observations  by  Brown-Sequard  and  by  Ollivier 
have  proved  its  association  with  central  nervous  lesions,  and  have 
demonstrated  its  occurrence  on  the  same  side  as  the  brain-lesion;^ 
which  is  not  the  case  with  reference  to  the  ordinary  acute  pulmonary 
diseases,  for  these  Rosenbach  has  shown  to  be  much  more  frequent 
on  the  paralyzed  side  of  the  body,  and  therefore,  generally,  on  the 
side  opposite  to  the  cerebral  mischief.  Pulmonary  apoplexy,  or 
"  hemorrhagic  infarct,"  is  also  met  with  in  malignant  fevers. 

Of  the  other  diseases  mentioned  which  resemble  pneumonia,  the 
distinguishing  points  need  not  be  here  fully  described.  Acute  pleurisy 
will  be  farther  on  more  particularly  studied.  With  regard  to  aeute 
phthisis,  it   is  only  necessary  to  repeat   that  cases  are  encountered, 

1  Arch.  Gen.  de  Med.,  Aug.  1873. 


DISEASES  OF  THE  LUNGS.  341 

apparently  of  pneumonia,  in  which,  after  the  symptoms  of  acute 
inflammation  of  the  lung  pass  off,  those  of  phthisis  come  into  the 
foreground.  With  reference  to  acute  bronchitis,  I  shall  merely  recall 
that  no  percussion  dulness  is  yielded  by  an  inflamed  bronchial  mem- 
brane. Percussion  is  thus  of  signal  value  in  the  diagnosis  of  pneu- 
monia. In  fact,  when  bronchitis  complicates  pneumonia,  and  loud, 
dry  rales  take  the  place  of  the  blowing  respiration,  it  is  our  only 
trustworthy  guide.  A  single  tap  on  the  chest  which  elicits  an  abso- 
lutely dull  sound  tells  the  difference  between  pure  bronchitis  and  the 
inflammation  of  the  bronchial  mucous  membrane  which  accompanies 
inflammation  of  the  parenchymatous  structure  of  the  lung. 

The  form  of  pneumonia  most  liable  to  be  mistaken  for  bronchitis 
is  the  pneumonia  of  childhood  or  of  old  age,  broncho -pneumonia  or 
catarrhal  pneumonia.  But  the  disease  may  also  occur  in  adults  of 
any  age. 

Broncho-Pneumonia. — It  mostly  supervenes  upon  acute  bronchitis, 
except  in  instances  in  which  it  arises  from  inhaling  irritating  gases. 
The  spread  of  the  disease  to  the  lung-texture  is  attended  with  rapid 
rise  of  temperature.  When  the  disorder  attacks  adults,  it  is  apt  to 
seize  upon  those  debilitated  by  previous  disease ;  it  much  more  com- 
monly affects  the  upper  lobes  than  does  acute  croupous  pneumonia, 
and  is  generally  bilateral.  As  the  broncho-pneumonia  merely  solidi- 
fies lobules,  the  signs  of  marked  consolidation  are  wanting,  or  are 
perceptible  over  only  a  small  space.  Crepitation^ is  not  common,  but 
small  moist  rales  are ;  bronchial  breathing  and  increased  fremitus 
show  only  over  limited  points ;  and  the  sputum  is  not  rusty  and 
viscid,  but  catarrhal.  Cough  and  expectoration,  sometimes  absent  in 
croupous  pneumonia,  are  always  present  in  broncho-pneumonia. 

Catarrhal  pneumonia,  or  broncho-pneumonia,  is  often  noticed  as  a 
complication  of  the  infectious  fevers,  especially  measles  and  diph- 
theria. It  is  the  form  of  pneumonia  developed  when  particles  of  food 
pass  into  the  larynx  and  bronchial  tubes, — aspiration  or  deglutition 
pneumonia.  Catarrhal  pneumonia  pursues  a  much  slower  course 
than  croupous  pneumonia,  and  generally  yields  only  gradually.  The 
consolidation  may  continue  stationary  for  weeks,  showing  a  fever  with 
marked  daily  remissions  and  exacerbations,  like  a  hectic  fever,  and 
then  slowly  disappear.  As  interstitial  inflammation  of  the  bronchi 
and  alveolar  walls  is  distinctive  of  the  disease,  and  as  the  perivesicular 
structures  are  markedly  involved,  persistent  local  consolidation  from 
interstitial  pneumonia  or  fibroid  phthisis  often  follows.  On  the  other 
hand,  caseous  degeneration  and  breaking-down  of  the  lung-texture 
may   follow,    or   extended    tubercular   infiltration   become    manifest. 


342  MEDICAL  DIAGNOSIS. 

Whether  the  bacillus  finds  in  the  consolidated  lung  a  ready  lodging, 
or  the  broncho-pneumonia  is  originally  excited  by  the  bacillus,  phthisis 
is,  in  truth,  in  adults  a  not  uncommon  termination ;  in  children,  too, 
this  may  happen,  or  rhachitis  may  develop,  or  an  ill-defined  but 
persistent  cachexia,  with  a  great  tendency  to  catch  cold. 

There  is  a  form  of  broncho-pneumonia,  described  as  tuberculous 
aspiration  broncho-jmeumonia^  that  follows  hemorrhage  from  tubercu- 
lar cavities.  It  is  usually  preceded  by  active  physical  effort,  and  its 
first  manifestation  is  a  hemorrhage.^  An  asjnrotion  pneumonia  may 
also  follow  hgemoptysis  from  other  causes,  or  be  met  with  as  the  con- 
sequence of  aspirated  particles  from  a  bronchiectatic  cavity,  or  from 
an  empyema  that  has  ruptured  into  the  lung,  or  after  tracheotomy,  or 
in  cancerous  affections  of  the  larynx  and  oesophagus.  It  not  unusually 
leads  to  suppuration. 

Pneumonia  often  shows  itself  in  an  epidemic  form,  and  is  now 
generally  looked  upon  as  an  infectious  disease,  a  lung  fever ;  indeed, 
except  as  a  matter  of  clinical  convenience,  it  should  not  be  described 
with  pulmonary  diseases.  The  evidence  of  a  micro-organism  as  its 
cause  is  very  strong.  The  diplococcus  pneumonias  was  found  inde- 
pendently by  Pasteur  and  by  Sternberg,  and  has  been  fully  studied  by 
Fraenkel,  after  whom  it  has  been  named.  It  is  present  in  the  buccal 
secretion  of  a  certain  number  of  healthy  persons.  Its  association  with 
catarrhal  pneumonia  is  not  so  close  as  with  croupous  pneumonia.  In 
truth,  the  bacillus  of  tubercle  at  times  excites  this,  making  a  specific 
broncho-pneumonia  from  the  start ;  the  staphylococcus  and  the  strep- 
tococcus pyogenes  may  also  induce  it,  as  Northrup's  observations 
clearly  prove. 

The  cocci  are  best  stained  in  dilute  alcoholic  solutions  of  the 
aniline  dyes,  and  are  readily  seen  in  preparations  colored  by  Gram's 
method.  In  this  respect  they  differ  from  the  pneumo-bacillus  of 
Friedlaender,  which  is  also  found  in  a  certain  proportion  of  pneu- 
monic lungs,  but  does  not  retain  the  stain  after  going  through  the 
process.  The  Fraenkel  coccus  is  elongated  or  round,  enveloped  in  a 
capsule,  and  often  found  in  pairs. 

The  micro-organism  of  pneumonia  generally  appears  at  the  height 
of  the  malady.  It  has  been  found  in  the  blood,  in  the  meningitis  that 
at  times  attends  pneumonia,  in  the  accompanying  pleurisy,  and  in  the 
lung  complication  of  ulcerative  endocarditis.  The  organism  is  also 
met  with  in  other  conditions  than  in  connection  with  pneumonia,  as 
in  pericarditis,  peritonitis,  acute  synovitis. 

'  Bitumler,  Deutsche  Medicinische  Wochenschrift,  No.  1,  1893. 


DISEASES  OF  THE  LUNGS. 


343 


Fig.  37. 


CLINICAL  NOTES 


344  MEDICAL   DIAGNOSIS. 

There  are  some  varieties  of  pneumonia  that  present  dinical 
features  of  a  pecuhar  kind.  Apex  pneumonia  is  one.  It  is  more 
usual  in  children  than  in  adults,  and  the  frequency  with  which  cere- 
bral symptoms  arise  and  draw  away  attention  from  the  chest  is  a 
matter  of  common  observation.  The  cases,  as  a  rule,  are  severe,  and 
the  temperature  is  high.  Double  pneumonia  differs  in  notliing  from 
ordinary  pneumonia  except  in  the  severity  of  the  symptoms.  The 
cases,  unless  speedily  fatal,  are  generally  of  longer  duration,  and  the 
temperature  is  less  characteristic,  for  the  reason  that  it  rarely  happens 
that  both  lungs  are  affected  at  the  same  time.  Double  pneumonia  is 
rare ;  what  is  called  double  pneumonia  is  generally  inflammation  of 
one  lung  and  heavy  congestion  of  the  other.     Latent  pneumonia  is 

Fig.  38. 


/ 
/ 


The  diplococcus  pneumonise  of  Fi-aenkel ;  the  cocci  are  stained  darJi  blue,  the  capsules  are 
unstained.     (After  von  Jaksch.) 

not  often  seen  except  in  the  aged.  There  is  but  little  fever,  and  it  is 
only  by  the  physical  signs  that  the  disease  can  be  recognized.  Migra- 
tory pneumonia.,  a  condition  in  which  different  parts  of  the  lung  are 
successively  involved,  is  not  a  frequent  disease.  The  temperature 
shows  a  tendency  to  sudden  falls,  with  rapid  rises  whenever  a  fresh 
part  of  the  lung  is  involved.  Some  of  the  older  clinicians,  especiahy 
Wunderlich  and  Trousseau,  regard  the  disease  as  having  a  close 
connection  with  erysipelas. 

It  is  always  very  important  to  find  out  whether  pneumonia  is 
primary  or  intercurrent  in  some  other  malady,  such  as  in  rheumatism, 
Bright's  disease,  diabetes,  the  exanthemata,  influenza,  the  typh-fevers, 
or  in  septic  states.  At  times  it  is  distinctly  noticed  to  follow  contu- 
sions of  the  chest.     As  has  been  already  said,  it  may  be  epidemic. 


DISEASES  OF  THE  LUNGS. 


345 


By  the  symptoms  and  physical  signs  we  cannot  distinguish  the  spo- 
radic and  simple  cases  from  those  of  the  infectious  malady.  Further 
bacteriological  research  may  solve  the  matter. 

There  are  two  other  forms  of  pneumonia  which,  as  they  present 
somewhat  peculiar  symptoms,  require  further  to  be  noticed.  They 
are  typhoid  pneumonia  and  bilious  pneumonia. 

Fig.  39. 


Pneumococcus  (diplococcus)  of  Friedlaender,  without  the  capsule,  from  a  pure  culture  upon 
gelatin  from  the  sputum  in  a  case  of  croupous  pneumonia  at  the  Pennsylvania  Hospital.  (Drawn 
by  Dr.  Joseph  Leidy,  Jr.) 


Typhoid  Pneumonia. — The  term  typhoid  pneumonia  is  applied  by 
some  to  the  inflammation  of  the  lung  which  may  complicate  typhus 
or  typhoid  fever ;  it  has  been  also  made  to  include  an  idiopathic  fever 
in  which  the  affection  of  the  respiratory  organs  is  occasionally  wanting. 
To  neither  of  these  maladies  rightly  belongs  the  name  typhoid  pneu- 
monia, since  in  both  the  inflammation  of  the  lung  is  but  an  incidental 
accompaniment.  Then  under  the  name  of  pneumo-typhus  a  disease 
has  been  of  late  years  described,  especially  by  German  clinicians,  in 
which  typhoid  fever  begins  with  a  well-defined  pneumonia,  that  for 
the  time  being  throws  the  enteric  symptoms  into  the  shade. 

Typhoid  pneumonia  is  pneumonia  with  symptoms  of  a  typhoid 
type,  and  marked  by  rapid  failure  of  the  vital  powers.  The  malady 
is  noticed  as  a  consequence  of  phlebitis ;  as  supervening  in  cases  of 
erysipelas,  of  Bright's  disease,  and  of  delirium  tremens  ;  or  as  the 
sole  apparent  affection.     It  happens  not  infrequently  in    epidemics. 


346  MEDICAL  DIAGNOSIS. 

and  is  very  often  observed  among  negroes.  Its  ravages  on  the  plan- 
tations of  South  CaroHna  and  Georgia  are  sometimes  frightful.  It  is, 
also,  very  fatal  in  jails,  and  among  troops  in  the  field  serving  under 
unfavorable  hygienic  conditions. 

The  physical  signs  are  those  of  the  sthenic  form  of  the  disease, 
except,  perhaps,  that  the  crepitant  rale  is  less  frequent.  Most  of  the 
same  symptoms,  too,  show  themselves :  cough,  short  breathing,  and 
pain  in  the  chest.  All  of  these  may  be  very  marked,  or  so  trifling  as 
hardly  to  direct  attention  to  the  lungs.  There  is,  however,  one  symp- 
tom characteristic  and  constant,  and  but  one,  and  that  is  the  great 
tendency  to  sinking.  As  regards  the  expectoration,  it  may  be  rusty- 
colored  ;  yet  occasionally,  even  in  the  early  stages,  it  consists  of  pure 
blood.  The  pulse  is  quick,  but  weak ;  dark  sordes  often  collect  on 
the  teeth  and  gums.  Pain  is  absent  in  some  cases,  and  extremely 
acute  and  of  a  radiating  character  in  others.  Concerning  delirium, 
we  know  that  it  is  much  more  common  than  it  is  in  the  sthenic 
variety  of  pulmonary  inflammation,  except  this  affect  the  apex  in 
children.  The  flush  on  the  face  is  usually  of  a  dusky  hue,  but  not 
invariably :  a  pink-colored  blush,  extending  sometimes  all  over  the 
body,  has  specially  attracted  attention.  The  disease  is  always  dan- 
gerous, and,  as  Stokes^  points  out,  resolution  is  extremely  slow. 
Chronic  hepatization,  with  or  without  a  low  hectic  fever,  or  a  lurking 
congestion,  may  continue  for  weeks. 

The  symptoms  of  typhoid  pneumonia  are  at  times  strangely 
mixed  with  those  produced  by  other  conditions.  In  many  districts 
in  which  the  complaint  is  prevalent,  it  bears  the  distinct  impress  of 
malaria.  Again,  articular  symptoms  seem  to  predominate  in  some 
regions  of  country,  and  in  some  epidemics.  Gibbes^  speaks  of  an 
acute  pain  in  the  back  part  of  the  eye,  in  the  ears,  or  in  the  side  of 
the  neck,  attended  with  stiffness  of  the  muscles  ;  and  of  a  swelling  of 
the  tonsils,  and  of  the  submaxillary  and  sublingual  glands. 

Bilious  Pneumonia. — Jaundice  and  other  indications  of  hepatic  and 
gastric  derangement  are  not  usual  in  ordinary  sthenic  pneumonia. 
They  may  be  occasionally  caused  by  the  inflammation  spreading  to 
the  liver,  or  may  be  of  blood  origin.  But  in  the  pneumonia  so  gen- 
eral in  the  spring  and  the  autumn  in  the  miasmatic  regions  of  some 
of  the  Southern  and  Western  States  of  this  country,  hepatic  symp- 
toms are  common,  and  mark  a  special  type  of  the  disease,  known  as 
malarial  pneumonia  or  bihous  pneumonia,  or  by  the  familiar  name  of 
"  bilious  pleurisy." 


Diseases  of  the  Chest.  ^  Amer.  Journ.  Med.  Sci.,  1842. 


DISEASES  OF  THE  LUNGS. 


347 


This  form  of  inflammation  of  the  lung  is  simply  pneumonia, 
sthenic  or  asthenic,  on  whose  features  the  stamp  of  malaria  is  im- 
printed. The  chill  with  which  it  begins  is  usually  protracted,  and 
is  followed  by  pain  in  the  side,  by  fever,  by  hurried  breathing,  and 
by  cough.  The  pain  in  the  side,  which  depends  upon  accompanying 
pleurisy,  is  sharp,  and  renders  the  respiration  irregular.  The  sputum 
is  at  times  rusty-colored,  while  at  others  a  frothy  and  bloody  serum 
or  pure  blood  is  expectorated.  The  fever  is  much  more  paroxysmal 
than  in  the  other  varieties  of  the  malady.  This  peculiarity,  and  the 
obvious  symptoms  of  hepatic  and  gastric  disorder,  are  indeed  the  only 
distinguishing  traits  of  bilious  pneumonia.  The  febrile  exacerbations 
are  stated  by  Manson,  of  North  Carolina,  to  be  preceded,  during  the 


Fig.  40. 


Friction  sounfl . 


Roughening  of  the  pleura  from  inflammation  ;  a  small  amount  of  fluid  has  begun  to  collect. 

morning  hours,  by  an  insensible  chill, — a  coolness  of  the  ends  of  the 
nose,  fingers,  and  toes,  which,  in  grave  cases,  extends  over  the  entire 
extremities.  The  rusty  sputum  has  been  noticed  to  occur  intermit- 
tently in  undoubted  diplococcus  pneumonia.^  In  cases  of  malarial 
pneumonia  the  malarial  parasite  has  been  found. 

The  physical  signs  are  those  of  ordinary  acute  pneumonia.     Bron- 
chial breathing  and  bronchophony  are  said  to  be  more  often  absent. 


Mader,  Wiener  klinische  Wochenschrift,  viii.  22,  1896. 


348 


MEDICAL  DIAGNOSIS. 


or  to  appear  and  disappear  rapidly.  It  is  certain,  if  this  be  true,  that 
in  these  instances  the  malady  could  not  have  been  inflammation,  but 
was  more  probably  a  collapse  of  the  pulmonary  tissue  occurring  in 
the  course  of  malarial  fever. 

Acute  Pleurisy. — Acute  pleurisy  has  been  so  often  incidentally 
mentioned  that  a  description  of  its  main  points  will  here  suffice.  It 
comes  on  from  cold  or  exposure,  or  from  injuries  to  the  chest ;  but  a 
great  many  cases  are  secondary  to  some  general  or  infectious  malady. 


Fig.  41. 


Great  dulness 

Absent  voice 

Absent  respiration. 
Absent  fremitus . . . 


Examination  of  the  posterior  portion  of  the  chest  while  a  large  effusion  is  occupying  the  left  pleural 

ca's^tv. 


The  first  effect  of  the  inflammation  is  to  redden  the  pleural  mem- 
brane ;  an  exudation  of  a  soft,  grayish,  easily  detached  lymph  then 
takes  place.  This  constitutes  the  first  or  dry  stag'e  of  the  cUsease ; 
and  if  the  two  inflamed  surfaces  unite,  the  disorder  does  not  pass 
beyond  this  stage.  Often,  however,  along  with  the  exudation  of 
lymph  occurs  an  effusion  of  serum,  which  produces  a  special  train 
of  phenomena,  and  gives-  rise  to  the  second  stage,  or  that  of  liquid 
effusion. 

The  physical  signs  of  the  dry  stage  are  impaired  movement  of  the 
chest,  a  feebler  respiration,  and  a  friction  sound  of  varying  extent  and 


DISEASES  OF  THE  LUNGS.  349 

intensity.  The  first  two  signs  are  caused  by  the  patient  instinctively 
refraining  from  expanding  the  lung,  because  of  the  pain  it  occasions. 
The  mechanism  of  the  friction  sound,  its  nature,  its  superficial  char- 
acter and  want  of  uniformity,  have  been  pointed  out  in  a  previous 
part  of  this  chapter.  In  the  stage  of  effusion  the  physical  signs  differ 
according  to  the  amount  of  fluid  the  pleural  cavity  contains.  A  mod- 
erate quantity  of  liquid  only  constricts  the  lung-texture,  and  leaves 
the  bronchial  tubes  intact ;  a  large  accumulation  compresses  every- 
thing ;  it  drives  all  air  out  of  the  lung,  pushes  it  into  a  small  space 
against  the  vertebral  column,  and  displaces  the  liver  or  heart.  Where- 
ever  the  fluid  accumulates  there  is  dulness  on  percussion.  When  the 
patient  is  in  the  erect  posture,  the  flat  sound  on  striking  the  chest  and 
the  sense  of  resistance  to' the  finger  are  marked  at  the  lower  part  of 
the  thorax,  since  the  fluid  naturally  settles  there.  The  line  of  dulness 
is,  however,  not  the  same  in  front  as  it  is  behind.  It  is  generally  much 
higher  behind,  and  alters,  of  course,  with  the  changing  quantity  of 
effusion,  and  somewhat  with  the  position  of  the  patient.  When  he 
lies  upon  his  face,  the  fluid  gra\itates,  if  not  circumscribed  by  adhe- 
sions, towards  the  anterior  chest  walls,  and  the  percussion  dulness 
posteriorly  becomes  far  less  perceptible.  The  peculiar  curve  of  the 
percussion  Ime  often  found  has  been  specially  described  by  Calvin 
Ellis,  and  is  named  by  Garland  the  letter  S  curve.^  Another  sign  of  a 
pleuritic  effusion  is  the  one  found  by  Kellock.^  It  consists  in  per- 
cussing posteriorly  with  force  on  the  ribs  of  the  side  suspected  with 
the  right  hand,  while  the  left  hand  is  placed  firmly  on  the  lower  part 
of  the  thoracic  wall  just  below  the  nipple.  The  vibration  of  the  rib 
struck  posteriorly  is  felt  by  the  left  hand  in  front  with  greatly  increased 
distinctness,  if  fluid  be  present  in  the  pleura. 

Where  the  effusion  is  extensive,  the  intercostal  spaces  are  widened 
and  their  depressions  effaced.  The  side  is  distended,  fluctuation  may 
be  perceived,  and,  owing  to  the  absolute  compression  of  the  lung,  no 
sound  is  heard  over  the  chest  when  the  patient  breathes,  or  speaks, 
or  coughs.  In  more  moderate  collections  of  fluid,  the  cessation  of 
sound  is  not  so  absolute.  There  is  an  ill-deflned,  deep-seated  respi- 
ration, and  the  voice  reaches  the  ear  with  tolerable  distinctness,  and 
occasionally  with  a  peculiar  bleatmg  resonance  attending  it.  But,  as 
large  collections  of  fluid  are  more-  common  than  small  ones,  the  former 
set  of  phenomena  are,  at  the  height  of  the  disease,  more  frequent  than 
the  latter.    Occasionally  the  expiration  has  a  metallic  sound,  and  there 

^  Pneumono-Dynamics,  1878,  and  New  York  Medical  Journal,  Nov.  1879. 
''  Lancet,  March  28,  1896. 

22 


350  MEDICAL  DIAGNOSIS. 

are  resonant  rales  suggesting  a  cavity.  Tliese  pseudo-cavernous  signs 
are  most  apt  to  be  met  with  in  cMlclren. 

Above  the  Kquid  there  is  increased  resonance  on  percussion,  or  a 
tympanitic  sound,  Skoda's  sound.  Tliis  tympanitic  sound  is  more 
manifest  at  the  upper  part  of  the  chest  in  front ;  it  may  be,  indeed, 
found  in  front  wlien  it  does  not  exist  belimd.  In  some  cases  the 
sound  has  an  amphoric,  in  others  a  cracked-metal,  character,  AATien 
the  ear  is  applied  above  the  line  of  percussion  dulness,  it  recognizes 
occasionally  a  friction  sound ;  and  near  the  spinal  column  posteriorly, 
where  the  compressed  lung  lies,  it  perceives  almost  invariably  distinct 
bronchial  respiration  and  bronchophony. 

When  the  fluid  begins  to  be  absorbed,  the  voice  becomes  more 
audible  over  the  seat  of  the  effusion,  the  vocal  vibrations  may  be 
felt  by  the  fingers,  and  the  respiration  is  again  heard.  But  for  a 
long  time  it  continues  enfeebled,  and  its  character  is  indeterminate ; 
it  is  neither  vesicular  nor  purely  bronchial.  As  more  and  more  of 
the  fluid  disappears,  the  voice  becomes  more  and  more  distinct ;  a 
friction  sound  finally  shows  that  the  roughened  surfaces  have  come 
in  contact ;  and  the  dulness  on  percussion  is  replaced  by  a  far  clearer 
sound.  False  membranes  now  unite  the  two  plurse ;  the  intercostal 
spaces  resume  their  normal  shape  ;  and  the  chest  is  either  restored 
to  its  natural  size,  or  is  left  somewhat  contracted.  The  bronchial 
breathing  near  the  vertebral  column  persists  for  a  long  time. 

These  physical  signs  have  been  discussed  first  because  they  are 
the  most  important  elements  in  the  diagnosis  of  pleurisy.  The  symp- 
toms, indeed,  often  hardly  attract  attention ;  and  if  we  trusted  to 
them,  we  should  be  groping  in  the  dark.  Pleurisy  mostly  begins  "v^ith 
a  chm,  followed  by  fever  and  by  a  dry,  irritating  cough.  The  most 
distinctive,  though  not  a  constant,  symptom  of  the  first  stage  is  the 
sharp,  acute  pain,  the  "  stitch  in  the  side.""  It  is  commonly  felt  under 
the  nipple  or  in  the  axilla,  and  is  somewhat  increased  on  pressure. 
Its  seat  by  no  means  always  corresponds  to  the  seat  of  the  friction 
sound.  As  the  effusion  takes  place,  the  pain  disappears,  dyspnoea  be- 
comes evident,  and  the  patient  ordinarily  lies  on  the  affected  side. 
The  febrile  symptoms  and  dry  cough  continue  ;  yet  neither  is  marked, 
and  both  disappear  long  before  the  fluid  is  entirely  alDSorbed.  The 
decubitus  is  generally  on  the  affected  side. 

Pleurisy  may  be  idiopathic,  coming  on  generally  after  exposure  to 
cold  and  damp ;  or  it  may  be  an  attendant  upon  other  diseases  of 
the  lungs,  such  as  pneumonia  or  tuberculosis,  or  may  accompany 
measles,  scarlatina,  typhoid  and  typhus  fevers.  It  may  also  be  caused 
by  wounds  of  the  thoracic  walls,  by  rheumatism,  gout,  Bright"s  dis- 


DISEASES  OF  THE  LUNGS.  351 

ease,  diphtheria,  pyaBiiiia,  cirrhosis  of  the  hver,  and  other  morbid 
states.  We  may,  too,  though  rarely,  meet  mth  a  prmiary  acute 
tuberculosis  of  the  pleura,  which  may  rapidly  become  suppurative. 

The  malady  with  which  acute  pleurisy  is  most  likely  to  be  con- 
founded is  acute  pneumonia.  Both  are  affections  occasioning  dysp- 
noea ;  both  are,  in  the  majority  of  cases,  one-sided ;  both  present 
dulness  on  percussion.  But  the  dulness  in  the  latter  disease  is  far 
less  absolute  than  in  the  former ;  nor  do  we,  save  in  rare  instances, 
meet  with  a  tympanitic  or  an  amphoric  percussion  sound  in  pneu- 
monia, while  in  pleurisy,  as  we  have  just  seen,  it  is  far  from  unusual 
above  the  level  of  the  fluid.  In  the  few  cases  in  which  a  tympanitic 
or  an  amphoric  sound  is  perceived  in  pneumonia,  the  peculiar  tone  is 
most  obvious  over  the  consolidated  tissue. 

The  other  physical  signs  of  the  two  diseases  show  still  less  simili- 
tude. The  absence  of  respiration,  of  vocal  resonance,  and  of  thrill 
is  in  striking  contrast  with  the  loud  blowing  respiration,  the  strong 
chest-voice,  and  the  increased  vocal  thrill  of  pneumonia.  There  are, 
however,  exceptional  cases  of  pleuritic  effusion,  in  which  bronchial 
breathing  is  heard  all  over  one  side  of  the  chest.  Especially  does 
this  happen  if  pneumonic  consolidation  accompany  the  effusion  ;  but 
even  in  simple  compression  of  the  lung,  and  where  the  collection  of 
liquid  is  not  extensive,  bronchial  respiration  may  be  perceived.  The 
difficulty  of  distinguishing  from  pneumonia  suiSi  cases  of  pleurisy,  in 
which  probably  the  lung-tissue  is  compressed  around  the  bronchial 
tuJDes,  is  great.  As  aids  in  diagnosis,  we  seek  for  dilatation  of  the- 
chest ;  we  note  the  peculiarities  of  the  breathing,  which,  although 
blowing,  is  mostly  famter  than,  and  unlike,  the  high-pitched,  brazen 
respiration  of  pneumonia ;  we  find  that  the  percussion  dulness  over 
the  upper  part  and  where  the  bronchial  respiration  is  most  distinct  is. 
not  very  great,  and,  especially,  that  it  disappears  on  respiratory  per- 
cussion ;  we  observe  that  the  voice  is  less  strong  and  ringing,  and 
has,  perhaps,  a  bleating  tone ;  and  we  take  into  account  the  appear- 
ance of  the  sputum  and  the  character  of  the  fever.  On  the  other 
hand,  pneumonia  may  present  itself  in  a  form  almost  unchstinguish- 
able  from  pleurisy  in  the  stage  of  effusion ;  it  is  when  the  bronchial 
tubes  as  well  as  the  lung  structure  are  filled  with  a  fibrinous  exuda- 
tion. In  this  massive  jyneumonia  we  do  not  find  either  tubular  breath- 
ing or  fremitus  attending  the  flat  percussion  note,  and  it  is  only  by 
noting  the  absence  of  displacement  of  the  heart  or  the  liver,  the  vio- 
lent coughing  spells,  and  observing  the  fragments  of  moulds  of  the 
bronchi  in  the  expectoration  that  a  conclusion  can  be  arrived  at. 

In  the  first  stage  of  pleurisy  the  pain  might  cause  the  disease  to  be 


352  MEDICAL  DIAGNOSIS. 

confounded  with  pleurodynia  or  intercostal  neuralgia.  In  all  three 
pain  is  the  prominent  symptom.     Let  us  see  how  it  differs  in  each : 

Pleurodynia. — Pleurodynia  is  described  as  a  form  of  muscular 
rheumatism.  But  frequently  it  is  myalgia,  or  a  pleurisy  which  does 
not  pass  beyond  the  dry  stage.  Of  this  nature  are  most  of  the  fugi- 
tive chest-pains  from  which  phthisical  patients  suffer.  Yet  there  are 
cases  in  which  no  signs  whatever  of  pleurisy  exist,  but  which  are  at- 
tended with  as  much  pain  as  pleurisy.  The  pain  of  pleurodynia 
is  often,  indeed,  excessively  severe ;  the  patient  refrains  from  deep 
breathing,  since  every  motion  of  the  chest  increases  his  suffering. 
The  pain  is  augmented  by  movements  of  the  arm  and  by  pressure, 
and  is  generally  associated  with  tenderness.  Pleurodynia  shares  with 
pleurisy  the  feeble  respiration  and  the  want  of  action  of  the  affected 
side.  It  differs  from  it  by  the  absence  of  friction  sound  and  of  fever  ; 
by  the  shifting  pain,  often  double-sided  ;  and  by  the  greater  tenderness 
of  the  chest  walls. 

Intercostal  Neuralgia. — In  anaemic  women  and  in  consumptives 
acute  thoracic  pain  is  not  uncommonly  the  result  of  an  intercostal 
neuralgia.  The  same  want  of  expansion  of  the  chest  and  the  same 
enfeebled  breathing  as  in  pleurodynia  are  here  noted,  also  the  same 
absence  of  fever  and  of  pleural  friction.  The  distinguishing  marks 
of  intercostal  neuralgia  are :  its  intermittent  character ;  its  frequent 
association  with  uterifie  disturbance,  especially  with  leucorrhoea,  and 
the  limitation  of  the  tenderness  to  special  points  in  the  course  of  the 
affected  nerve.  Valleix  has  drawn  attention  to  three  painful  spots 
which  are  tender  to  the  touch :  one  at  the  exit  of  the  nerve  from  the 
spinal  column,  the  second  in  the  axillary  region,  and  the  third  near 
the  sternum  or  in  the  epigastric  region.  It  is  on  the  left  side  that  we 
are  most  apt  to  find  intercostal  neuralgia,  and  between  the  sixth  and 
ninth  ribs  that  the  painful  places  are  usually  detected. 

Pain  occurs  also  in  diseases  affecting  the  lung-texture.  There  is 
pain  of  a  dull  nature  in  pneumonia,  of  a  more  severe  character  in 
cancer.  But  the  pain  is  so  dissimilar,  and  the  coexisting  symptoms 
are  so  unlike,  that  the  confounding  of  these  maladies  with  pleurisy, 
on  account  of  the  pain,  is  not  likely. 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement 
of  the  Liver  or  Heart,  and  Dyspnoea. 
A  group  of  diseases  may  be  here  studied,  all  of  which  occasion 
more  or  less  dilatation  and  prominence  of  the  chest,  and  all  of  which 
are  attended  with  decided  shortness  of  breath.  In  the  recognition  of 
emphysema,  pneumothorax,  and  pleuritic  effusion,  the  dilatation  of 


DISEASES  OF  THE  LUNGS.  353 

the  thorax  forms  one  of  the  main  elements ;  moreover,  it  is  often 
combined  with  marked  dyspnoea  and  with  displacement  of  the  liver  or 
heart.  These  affections,  then,  may  be  examined  in  the  same  connec- 
tion, and  compared  with  one  another,  and  incidentally  with  several 
less  common  diseases  which  present  similar  manifestations. 

The  history  and  signs  of  emphysema  were  given  when  treating  of 
the  diseases  accompanied  by  clearness  on  percussion.  It  was  then 
mentioned  that  in  many  instances  the  prominence  of  the  chest  is  cir- 
cumscribed. Such  cases  cannot  be  mistaken  :  the  bulging  is  too  lim- 
ited. But  when  the  emphysema  is  more  general,  and  an  entire  side 
of  the  chest  or  the  whole  chest  becomes  dilated,  or  when  the  inflated 
lung  displaces  the  liver  or  heart,  the  affection  comes  into  the  group 
under  consideration.  A  patient  seeks  advice  for  shortness  of  breath. 
His  chest  is  inspected,  and  looks  enlarged.  The  physical  signs  prove 
that  the  disease  is  not  one  of  the  heart  or  an  aneurism.  What,  then, 
is  it  ?  Is  it  an  effusion  into  the  pleura  ?  is  it  an  intrathoracic  tumor  ? 
is  it  pneumothorax  ?  is  it  emphysema  ?  A  tap  on  the  chest  goes  far 
towards  showing  whether  it  is  the  former.  If  the  sound  rendered  be 
resonant,  it  is  not  liquid  in  the  chest  that  is  producing  the  disturbance, 
nor,  except  under  rare  circumstances,  an  intrathoracic  tumor :  the 
disorder  is  either  pneumothorax  or  emphysema. 

Pneumothorax. — Of  all  thoracic  maladies,  pneumothorax  is  the 
one  the  similarity  of  which  to  extensive  dilatation  of  the  air-cells  is  the 
greatest.  In  both,  the  large  quantity  of  air  occasions  increased  clear- 
ness on  percussion  ;  in  both,  there  is  considerable  and  persistent  diffi- 
culty of  breathing ;  in  both,  the  distention  of  the  chest  and  the  dis- 
placement of  organs  may  be  obvious.  In  pneumothorax,  however, 
the  symptoms  and  signs  are  associated  with  different  conditions. 
Pneumothorax  is  an  accumulation  of  air  in  the  pleural  cavity,  but  it 
is  something  more  :  the  entrance  of  air  is  soon  followed  by  the  effusion 
of  liquid. 

Air  is  let  into  the  cavity  of  the  chest  by  the  pleura  being  perforated 
by  wounds,  or  through  the  diaphragm  by  malignant  disease  of  the 
stomach  or  the  colon,  or,  as  is  most  common,  by  its  partial  destruc- 
tion consequent  upon  disease  of  the  lung.  It  is  in  this  way  pneumo- 
thorax originates  in  the  coiirse  of  tubercular  softening,  of  gangrene, 
of  pneumonia,  or  from  the  bursting  of  a  distended  air-vesicle  or  of  a 
dilated  bronchial  tube.^  In  the  large  ma.]ority  of  instances  it  occurs 
in  tubercular  patients. 

When  air  passes  from  the  lung  into  the  pleura,  it  usually  happens 


^  Case  recorded  by  Taylor,  Prov.  Med.  Jourii.,  vol.  i.,  1842. 


354 


MEDICAL  DIAGNOSIS. 


during  a  paroxysm  of  coughing.  The  pain  which  ensues  is  most  in- 
tense ;  and  with  it  there  is  suddenly  developed  dyspnoea.  If  death 
do  not  take  place,  symptoms  of  pleurisy  with  effusion  manifest  them- 
selves ;  and,  as  in  pleurisy,  the  patient  lies  ordinarily,  but  not  invari- 
ably, on  the  affected  side. 

The  distinctive  marks  of  pneumothorax  are  furnished  by  its  physi- 
cal signs.     The  ingress  of  air  into  the  pleural  cavity  widens  the  chest, 


Fig.  42. 


Physical  signs  in  pneumothorax  on  the  right  side.    The  heart  is  observed  to  be  displaced  towards 
the  left,  as  actually  happened  in  the  case  from  which  the  outline  was  taken.    The  percussion  reso- 
nance on  the  right  side  was  tympanitic,  extending  somewhat  over  the  left  margin  of  the  sternum 
the  fremitus  was  annulled ;  the  voice  metallic. 

effaces  the  depression  of  the  intercostal  spaces,  and  occasions  an  ex- 
tremely clear,  or,  more  correctly  speaking,  a  tympanitic,  sound  on 
percussion.  The  air  prevents  the  lung  from  expanding :  hence  there 
is  an  enfeebled  or  absent  respiration,  except  near  the  spinal  column, 
where  the  compressed  organ  lies,  and  where  the  breathing  is  bron- 
chial. The  hand,  if  laid  on  any  other  portion  of  the  chest,  feels, 
when  the  patient  speaks,  no  thrill,  and  no  vocal  vibration  is  detected 
by  the  ear.  When  the  perforation  has  not  closed,  and  the  air  rushes 
into  the  artificial  cavity  produced  by  the  separation  of  the  two  sur- 


DISEASES  OF  THE  LUNGS.  355 

faces  of  the  pleura,  the  respiration  is  amphoric,  or  it,  the  voice,  and 
the  rales  are  all  accompanied  by  a  distinct  metallic  ring ;  respiratory 
percussion,  too,  changes  the  sound  elicited,  rendering  it  duller. 
Drops  of  fluid  falling  into  the  cavity,  or  the  bursting  of  bubbles  on 
the  surface  of  the  liquid  in  the  pleura,  are  echoed  to  the  ear  with  a 
metallic  sound,  and  are  often  heard  as  a  silvery  tinkle.  A  metallic 
echoing  sound  is  also  obtained  if  the  ear  be  placed  on  the  back  over 
the  affected  side  while  a  coin  is  tapped  on  another  coin  in  front. 

The  presence  of  fluid  in  the  pleural  cavity  gives  rise  to  a  dull 
sound  on  percussion  at  the  lower  part  of  the  chest,  which  changes 
readily  with  the  position  of  the  patient,  and  to  a  splash,  perceptible 
to  the  ear  and  to  the  fmger,  when  the  thorax  is  suddenly  shaken. 
This  continues  until  the  effusion  increases,  and  until  the  opening 
closes,  the  air  disappears,  and  the  case  resolves  itself  into  one  of 
chronic  pleurisy, — the  most  favorable  termination  of  pneumothorax. 

Now  let  us  compare  the  physical  signs  with  those  produced  by 
emphysema.  The  sound  on  percussion  in  both  is  very  clear,  or  is 
tympanitic ;  more  so,  however,  in  pneumothorax,  which,  in  addition, 
exhibits  dulness  at  the  lower  part  of  the  chest.  The  respiration  in 
both  is  feeble.  But  it  is  feebler  in  pneumothorax,  and  not  accom- 
panied by  a  long,  laborious  expiration ;  besides,  it  is  often  amphoric, 
and  attended  with  metallic  voice  and  tinkling, — phenomena  which 
dilated  air-cells  cannot  occasion.  Moreover,  there  can  be  no  splash- 
ing sound  in  emphysema,  and  this  always  exists  in  pneumothorax, 
except  in  those  rare  instances  in  which  there  is  no  fluid  in  the  pleural 
cavity ;  on  the  other  hand,  the  displacement  of  the  heart  is  generally 
much  greater  in  pneumothorax,  and  the  dilatation  of  the  chest  more 
apt  to  be  one-sided.  Yet  too  much  stress  has  been  laid  on  the  latter 
point  as  a  means  of  distinction ;  for  emphysema  may  be  one-sided, 
and,  on  the  other  hand,  pneumothorax  may  occur  on  both  sides.  In 
some  cases  we  are  aided  in  the  discrimination  by  noticing  that  bulging 
is  perceptible  over  the  displaced  heart,  and  that  a  metallic  echo  fol- 
lows the  cardiac  sounds.  The  physical  signs  of  the  two  diseases  are 
thus  very  different ;  so,  too,  are  many  of  the  symptoms.  Difficulty  of 
breathing  exists  in  both.  But  in  emphysema  it  takes  generally  the 
form  of  asthma ;  besides,  it  does  not  set  in  suddenly  and  with  inten- 
sity, and  remain  intense.  In  pneumothorax  the  patient  remembers 
to  have  been  seized  with  a  pain  in  his  chest,  since  which  period  he 
has  been  continuously  short  of  breath. 

Yet  there  are  exceptions  to  this :  there  are  cases  in  which  the 
symptoms  occasioned  by  perforation  of  the  pleura  are  from  the  onset 
so  slight  as  not  to  attract  the  least  attention.     Such  cases  cannot  be 


356  MEDICAL   DIAGNOSIS. 

recognized,  save  by  their  physical  signs.  Among  these,  dilatation  of 
the  chest,  with  the  widened  intercostal  spaces,  the  displacement  of 
the  liver  or  heart,  and  the  exaggerated  and  altered  resonance  on  per- 
cussion are  most  valuable  in  preventing  the  disease  from  being  con- 
founded with  some  affections  which  in  other  respects  give  rise  to 
many  of  the  same  phenomena.  In  large  cavities,  for  instance,  the 
respiration  and  voice  may  be  metallic ;  metallic  tinkling,  nay,  even 
succussion,  may  occur.  But  the  prominent  chest,  the  extremely  clear, 
tympanitic,  or  metallic  sound  on  percussion,  bordered  by  the  line  of 
absolute  dulness  due  to  the  effusion,  are  not  met  with.  The  history 
also  is  different,  and  the  dyspnoea  is  not  so  great.  The  same  dissimi- 
larities will  prevent  us  from  mistaking  for  pneumothorax  a  pneumonia 
in  which  the  percussion  sound  over  the  consolidated  lung  is  tympa- 
nitic. And  a  study  of  the  physical  signs,  too,  will  at  once  enable  us  to 
discern  whether  the  difficulty  in  breathing — though  it  be  suddenly 
developed,  and  apparently  under  circumstances  which  make  the 
swallowing  of  a  foreign  body  seem  likely — be  due  to  this  cause,  or 
to  perforation  of  the  pleura  and  pneumothorax.^ 

There  is,  however,  a  morbid  condition  which  exhibits  nearly  all 
of  the  signs  and  many  of  the  symptoms  of  pneumothorax,  and  which, 
were  it  more  frequent,  would  be  the  source  of  constant  errors  of 
diagnosis , — diaphragmatic  hernia. 

Of  this  rare  affection  we  know  but  little.  Yet,  what  we  do  know 
of  it  teaches  us  that  a  protrusion  of  the  abdominal  organs  through 
the  diaphragm  will  generally  dilate  one  side  of  the  chest,  compress  the 
lung,  displace  the  heart,  and  result  in  dyspnoea ;  and,  as  the  stomach 
or  intestines  are,  for  the  most  part,  the  viscera  which  find  their  way 
into  the  chest,  metallic  tinkling  and  a  tympanitic  sound  on  percussion 
are  detected.  These  are  also  signs  of  pneumothorax.  There  is,  in- 
deed, no  mode  of  separating  the  two  diseases,  except  by  attention  to 
the  history  of  the  case,  by  noting  that  the  dyspnoea  of  the  former 
suddenly  appears  and  as  suddenly  disappears,  that  it  has  often  existed 
from  birth,  and  that  the  metallic  tinkling  happens  when  the  patient  is 
not  breathmg,  and  is  mixed  up  with  the  rumbling  sound  arising  in  the 
stomach  or  intestine. 

It  has  been  made  a  question  whether  we  can  distinguish  ordinary 
cases  of  pneumothorax  from  these  very  rare  ones  which  are  supposed 
to  occur  ivithout  perforation.  Now,  even  admitting  that  such  really 
happen,  as  a  sequence,  for  instance,  of  decomposition  in  pleuritic 
effusions,  there  are  no  signs  by  which  we  can  recognize  them  with 

^  As  in  a  case  of  the  disease  described  to  me  by  Dr.  Walter  F.  Atlee. 


DISEASES  OF  THE   LUNGS.  357 

certainty.  It  has  been  claimed  that  there  is  no  antecedent  history  of 
a  chronic  pulmonary  affection,  particularly  of  phthisis,  that  there  is 
not  that  suddenly  occurring  severe  pain  and  extreme  dyspnoea,  that 
the  sputum  and  breath  are  never  offensive,  that  metallic  tinklmg  is 
absent,  or  rare  and  inconstant,  and  that  the  amphoric  breathing  is  not 
so  well  developed  or  so  clearly  defined.  If  in  a  case  of  perforation, 
however,  the  opening  have  closed,  the  physical  signs  are  the  same. 

Chronic  Pleurisy. — Chronic  pleurisy  is  the  third  of  the  group  of 
more  usual  affections  characterized  by  dilatation  of  the  chest,  by  dis- 
placement of  the  intrathoracic  viscera,  and  by  shortness  of  breath. 
It  is  true  that  acute  pleurisy  in  the  stage  of  effusion  would,  strictly 
speaking,  find  here  a  place ;  but  the  acute  symptoms  bring  it  into 
another  class,  with  which  it  has  been  more  conveniently  described. 

Chronic  pleurisy  is  established  if  the  fluid,  after  an  acute  attack, 
be  not  absorbed,  or  if  an  accumulation  of  liquid  take  place  gradually, 
in  consecj[uence  of  subacute  inflammation  of  the  pleura.  It  is  also 
found,  especially  in  its  purulent  form,  in  a  number  of  infectious  dis- 
eases, particularly  scarlet  fever  and  typhoid  fever.  This  form  is  also 
seen  to  follow  pleuro-pneumonia  and  perforation  of  the  pleura  by 
softening  tubercle.  Chronic  pleurisy  has  no  constant  symptoms,  and 
is  often  remarkably  latent :  the  patient  frequently  does  not  remember 
to  have  had  acute  pleurisy.  He  is  not  commonly  troubled  with  much 
cough,  nor  is  the  want  of  breath  so  great  as  might  be  expected ;  he 
is  not  capable  of  talking  for  any  length  of  time,  or  in  a  loud  voice, 
but  he  does  not  really  suffer  from  dyspnoea.  His  general  health  may 
remain  good,  and  no  emaciation  occur.  In  some  persons,  on  the 
other  hand,  the  loss  of  flesh,  the  quickened  pulse,  the  sweats,  the 
paroxysms  of  hectic  fever,  are  so  marked  as  to  produce  a  close 
resemblance  to  the  last  stages  of  tubercular  consumption ;  and  there 
are  cases  with  misleading  marked  vasomotor  phenomena,  with  flushing 
and  sweating  of  one  cheek  and  dilatation  of  the  pupil. 

While  the  differing  symptoms  rather  hide  the  pleurisy  from  detec- 
tion, the  physical  signs  render  it  easy  of  recognition.  These  signs 
have  been  studied  in  describing  the  effusion  in  acute  pleurisy.  It  is 
only  necessary  to  recall  that  the  most  significant  are  absent  respiration 
and  voice,  a  flat  sound  on  percussion,  with  a  vesiculo-bronchial  or  a. 
bronchial  respiration  above  the  -seat  of  the  liquid.  The  intercostal 
spaces  are  strikingly  widened ;  their  depressions  are  effaced.  They 
are,  indeed,  sometimes  convex,  and  the  finger  pressed  on  them  detects 
a  distinct  fluctuation.  During  the  act  of  breathing,  the  diseased  side 
is  almost  motionless,  presenting  a  strong  contrast  to  the  obvious  play 
of  the  healthy  side.     The  lung  which  is  not  disturbed  increases  in 


358  MEDICAL  DIAGNOSIS. 

size.  Its  murmur  is  more  intense,  sometimes  harsher ;  and  the  per- 
cussion sound  over  it  is  exceedingly  clear.  In  some  cases  it  becomes 
emphysematous.  The  heart  or  liver  is  displaced.  A  lateral  cur^^ature 
of  the  spinal  column  is  apt  to  take  place,  and  the  shoulder  remains 
fixed  and  stiff  during  the  respiratory  acts.  To  distinguish  whether  the 
fluid  is  collected  in  one  cavity  or  in  several,  in  other  words,  whether 
unilocular  or  multilocular,  is  generally  mipossible.  Jaccoud^  has, 
however,  called  attention  to  some  points  which  aid  in  arnvmg  at  a 
conclusion.  If  we  have  a  zone  in  the  dulness  where  vocal  vibrations 
are  preserved,  as  at  the  posterior  part  of  the  chest  from  along  the 
vertebral  column  towards  the  sternum,  and  beyond  this  zone  no 
vibrations  are  perceived,  we  may  infer  that  the  effusion  is  divided  by 
a  band  of  pleural  adhesion ;  if  the  voice  and  fremitus  be  preserved, 
although  weakened,  over  the  whole  extent  of  the  dulness, — except  in 
a  zone  of  a  few  fmger-breadths  at  the  lower  part  of  the  chest  behind, 
— while  no  tympanitic  sound  is  elicited  under  the  clavicle,  we  may 
conclude  that  the  pleurisy  is  multilocular.  When  adhesions  to  the 
diaphragm  exist,  the  normal  movements  during  respiration  at  the 
epigastrium  and  hypochondrium  are  reversed,  and  at  each  inspiration 
a  marked  depression  of  the  inferior  intercostal  space  is  perceptible. 

Effusions  into  the  pleural  sac  may  last  for  a  long  time,  and  lead  to 
death  by  progressive  exhaustion ;  or  the  patient  may  recover  by  the 
fluid  being  absorbed,  or  by  its  finding  a  vent  through  the  bronchial 
tubes  or  the  thoracic  walls.  But  the  chest  is  rarely  restored  to  its 
former  state.  The  lung  was  too  much  compressed,  or  is  still  bound 
down  by  too  firm  adhesions,  to  resume  its  full  function.  The  walls 
of  the  chest  sink  in  around  it,  and  the  side  is  flattened,  is  duller  on 
percussion,  and  presents  a  feebler  breathing  than  the  other  Imig, 
which  remains  somewhat  enlarged.  The  heart  generally  returns  to  its 
normal  position,  but  the  shoulder  on  the  affected  side  is  apt  to  show  a 
permanent  depression. 

Notwithstandmg  the  decided  character  of  the  physical  signs, 
chronic  pleurisy  is  frequently  overlooked ;  and  we  hear  of  patients 
whose  pleural  cavity  is  filled  with  pus  being  pronounced  incurable 
consumptives,  because  they  are  emaciating  and  have  hectic  fever  and 
clubbed  nails  ;  or  being  treated  for  disease  of  the  heart,  on  account  of 
the  displacement  of  that  organ,  and  of  dyspnoea  and  oedema ;  or  being 
dosed  with  mercury,  for  an  imaginary  disorder  of  the  liver ;  or  being 
subjected  to  courses  of  quinine  and  arsenic,  to  check  a  rebelhous  ague 
which  the  chills  and  paroxysms  of  fever  at  times  simulate. 

^  Bulletin  de  I'Academie  de  Medecine,  1879. 


DISEASES  OF  THE  LUNGS.  359 

These  physical  signs  are  the  same  whether  the  fluid  be  serum  or 
pus.  The  character  of  the  fluid  produces,  indeed,  no  distinctive 
changes  either  in  the  signs  or  in  the  symptoms.  We  suspect  empyema 
if  the  emaciation  be  great  and  accompanied  by  decided  leucocytosis, 
high  temperature,  and  hectic  fever ;  but  I  have  known  pus  in  the 
chest  with  a  temperature  scarcely  above  the  norm,  and,  on  the  other 
hand,  the  accumulation  not  to  be  purulent  with  a  temperature  of 
103°,  Baccelh  has  proposed  a  new  and  simple  test  to  determine  the 
character  of  the  fluid,  which,  on  the  whole,  I  believe  to  be  of  use.  It 
consists  in  ascertaining  accurately  how  the  voice  penetrates,  espe- 
cially the  whispered  voice.  If  easily  and  thoroughly  transmitted,  the 
liquid  is  serous  and  homogeneous  ;  if  with  difficulty,  it  is  fibrinous  or 
purulent :  if  not  at  all,  it  is  the  latter.  In  cases  of  doubt  I  have  long 
been  in  the  habit  of  using  a  hypodermic  syringe  and  removing  with  it 
enough  of  the  fluid  for  microscopical  examination.  In  those  rare  in- 
stances in  which  pulsation  is  noticed,  the  fluid  is  only  seldom  sero- 
fibrinous ;  empyema  is  the  rule,  and  may  or  may  not  be  associated 
with  an  external  pulsating  tumor. 

The  microscopic  and  bacteriological  examination  of  the  exudation 
will  give  us  valuable  information.  In  rare  instances  the  fluid  consists 
of  fat-globules  and  of  masses  of  cholesterine.^  In  cases  of  hemor- 
rhagic pleurisy  the  haemoglobinometer  will  inform  us  accurately  as  to 
the  amount  of  blood  in  the  exudation.^  We  find  it,  indeed,  full  of 
blood  and  altered  blood  constituents  in  hemorrhagic  pleurisy,  a  form 
which  pleurisy  may  assume  in  cirrhosis  of  the  liver  and  low  fevers, 
but  which  is  more  frequently  found  in  cancerous,  and  sometimes  m 
tubercular  pleurisy.  In  the  latter  disease,  contrary  to  expectation, 
tubercle  bacilli,  as  we  know  from  the  observations  of  Ehrlich,  are 
often  absent.  There  is  a  group  of  cases  in  which,  either  in  a  serous 
or  a  purulent  exudate,  we  detect  the  diplococcus  pneumoniae ;  here 
there  may  or  may  not  have  been  a  preceding  pneumonia.  Cases  in 
which  the  diplococcus  pneumoniae  is  met  with  are  apt  to  set  in  with 
acute  symptoms  like  pneumonia,  and  are  generally  of  favorable  prog- 
nosis. In  septic  pleurisy  the  streptococcus  is  found,  and  especiahy, 
as  Koplik  has  shown,  the  streptococcus  pyogenes  ;  staphylococci  are 
also  met  with.  These  are  much  more  serious  cases,  both  as  to  dura- 
tion and  as  to  recovery.  A  sterile  fluid  pomts  to  tuberculosis.  Pleuri- 
sies with  the  typhoid  bacillus  are  sero-fibrinous  and  of  medium  gravity.^ 

'  Debove,  Soc.  Med.  des  Hopitaux  de  Paris,  tome  xviii.,  1881. 

2  Henry,  Medical  News,  April  14,  1888. 

^  Fernet,  Bull,  et  Mem.  de  la  Soc.  Med.  des  Hop.  de  Paris,  1895,  p.  145. 


360  MEDICAL  DIAGNOSIS. 

Leaving  out  pulmonary  consumption,  since  the  points  of  differ- 
ence have  been  already  discussed,  the  affections  ^vith  wliich  chronic 
pleurisy,  while  the  pleura  is  full  of  liquid  and  the  chest  enlarged,  is 
liable  to  be  confounded,  are  : 

Emphysema  and  Pneumothorax  ; 

Intrathoracic  Tumor  : 

Enlargement  of  the  Liver  ; 

Enlargement  of  the  Spleen ; 

Abscess  in  the  Thoracic  Walls  : 

Pericardial  Effusion  ; 

Htdrothorax. 

Emphysema-  and  Pneumothorax. — These,  although  such  different 
diseases,  are  grouped  together  because  they  give  rise,  like  chronic 
pleurisy,  to  a  dilated  chest,  and  to  displacement  of  the  liver  or  heart. 
But  the  other  signs  above  pointed  out,  which  indicate  the  presence  of 
air,  are  so  striking  that  an  error  m  diagnosis  can  only  be  the  result 
of  carelessness. 

Intrathoracic  Tumor. — A  tumor  within  the  chest  may  occasion  the 
same  distention  of  its  walls,  the  same  displacement  of  organs,  the 
same  dulness  on  percussion,  and  the  same  absent  respiration,  as  an 
effusion  of  liquid  into  the  pleura ;  yet  the  signs  are  not  exactly  alike. 
There  is  no  fluctuation  in  the  bulging  intercostal  spaces  ;  the  vocal 
fremitus  is  not  so  constantly  abolished ;  and  the  level  of  the  dulness 
is  not  changed  by  altering  the  patient's  position.  Nor  is  the  flat  sound 
so  uniform  or  so  strictly  limited  as  that  produced  by  fluid :  amid  the 
dulness  may  be  detected  here  and  there  a  spot  yielding  on  percussion 
a  clear  sound.  A  tumor  in  the  chest,  moreover,  presses  on  the 
nerves,  or  bronchial  tubes,  or  great  vessels,  and  thus  gives  rise  to 
severe  pain,  and  to  dyspnoea  and  signs  of  interrupted  circulation  far 
more  evident  than  those  caused  by  pleuritic  effusion.  It  not  infi'e- 
quently  grows  into  the  mediastinum,  and  then  leads  to  prominence  of 
the  sternum,  and  to  dilatation  of  both  sides  of  the  chest.  These 
phenomena  are  found,  whatever  be  the  nature  of  the  morbid  growth. 
As  most  of  the  thoracic  tumors  are  cancerous,  we  are  often  assisted 
in  our  diagnosis  by  discovering  a  cancer  in  other  parts  of  the  body, 
as  well  as  enlarged  cervical  glands,  and  by  noting  the  severe  pain  in 
the  chest,  the  harassing  cough,  and  the  expectoration  of  blood  or  of 
a  peculiar  jelly-like  substance.  Yet  these  evidences,  while  they  aid 
us  in  establishing  the  fact  of  a  new  growth  in  the  thoracic  cavity,  do 
not  by  any  means  determine  its  situation.  We  cannot  say  with  cer- 
tainty whether  the  abnormal  formation  is  situated  exclusively  in  the 
lung,  or  in  the  pleura,  or  whether  it  affects  both.     When  the  tumor 


DISEASES  OF  THE  LUNGS.  361 

occupies  the  mediastinal  spaces,  and  is  not  cancerous,  it  is  most  likely 
a  sarcoma.  Lymphadenomata  come  next  in  frequency.^  In  children, 
sarcoma  is  a  more  frequent  neoplasm  than  carcinoma.^ 

In  those  cases  in  which  an  effusion  into  the  pleura  complicates  an 
intrathoracic  tumor,  attention  to  the  history  and  to  the  signs  of 
pressure  alone  apprises  us  of  its  presence.  Yet  both  signs  and  symp- 
toms may  simulate  so  closely  those  of  chronic  pleurisy  as  to  render  a 
differential  diagnosis  impossible.  Nay,  friction  sounds,  a  stitch  in 
the  side,  and  fever  may  be  produced  by  a  cancer  of  the  2:)leura^  and  be 
so  rapidly  developed  as  to  cause  the  disease  to  be  regarded  as  an 
acute  or  a  subacute  inflammation  of  that  membrane.  The  most  cer- 
tain sign  is  probably  the  one  mentioned  by  Trousseau, — namely,  that 
the  fluid  which  is  evacuated  by  paracentesis  consists  of  a  bloody 
serum ;  yet,  though  of  great  significance  when  present,  its  absence  is 
not  so  valuable  a  test,  since  Moutard  Martin  found  hemorrhagic  effu- 
sion in  only  twelve  per  cent,  of  the  cases  he  analyzed.  Ehrlich  ^  has 
published  seven  cases,  in  three  of  which  he  detected  special  cellular 
elements  in  the  fluid,  and  was  thus  enabled  to  come  to  a  correct 
conclusion.  In  some  instances  there  is  no  fluid  in  a  greatly-thickened 
cancerous  pleura.* 

It  is  at  times  equally  impossible  to  distinguish  a  circumscribed  pleu- 
risy from  a  tumor  in  the  chest.  In  those  rare  cases  in  which  adhe- 
sions bind  the  licj[uid  effusion  and  encyst  it,  we  observe  all  the  marks 
of  a  tumor, — a  restricted  bulging  and  percussion  dulness,  and  absent 
respiration  and  tactile  fremitus,  though  the  latter  may  be  retained  over 
the  line  of  the  adhesions.  Several  cysts  may  form  as  the  result  of 
successive  attacks  of  pleurisy,  and  exist  in  any  portion  of  the  chest. 
The  fluid  may  be  cohected  in  the  mediastinum,  or  between  the  lobes 
of  the  lung,  or  anywhere  between  the  surfaces  of  the  pleural  mem- 
brane. The  purulent  contents  of  the  sac  sometmies  find  their  way 
into  the  bronchial  tubes,  and  are  expectorated,  or  give  rise  to  a  dis- 
tinct fluctuation  in  the  intercostal  spaces,  and  then  discharge  through 
the  thoracic  parietes.  In  such  cases  the  diagnosis  is  not  difficult. 
But  where  these  phenomena  are  not  present,  the  dissimilar  history  of 
the  case  and  the  absence  of  pressure  symptoms  are  the  only  means 
of  distinction  from  a  tumor  in  the  chest.  Fortunately,  encysted  pleu- 
risy is  a  rare  disease  ;  were  it  frequent,  it  would  be  a  fruitful  source 

^  Hobart  A.  Hare,  Affections  of  the  Mediastinum,  1889. 

^  Edwards,  Archives  of  Pediatrics,  July,  1889. 

»  Charite  Annalen,  1882. 

*  Purjesz,  Deutsches  Archiv  fur  klinische  Medicin,  Aug.  1883. 


362  MEDICAL  DIAGNOSIS. 

of  error.  The  same  remark  applies  to  hydatid  cysts,  which  may  occa- 
sion all  the  signs  of  a  circumscribed  pleurisy.  An  examination  of  the 
fluid  obtained  by  an  exploratory  puncture,  m  which  echinococci  are 
found,  is  the  only  positive  test. 

Enlargement  of  the  Liver. — An  enlarged  liver  usually  descends  into 
the  abdominal  cavity ;  yet  it  may  be  forced  upward  as  far  as  the 
fourth  rib,  and,  by  encroaching  upon  the  lung,  may  give  rise  to  many 
of  the  physical  signs  of  a  pleural  effusion.  The  surest  diagnostic  test 
is,  that  during  full  inspiration  and  expiration  the  line  of  dulness  de- 
scends and  ascends ;  while  the  flat  sound  of  an  effusion  is  not  afi'ected 
by  the  play  of  the  lungs.  This  test  will  be  applicable  except  where 
the  liver  is  firmly  adherent  to  the  walls  of  the  abdomen.  As  aids  in 
discriminating  between  the  enlargement  of  the  abdominal  organ  and 
the  presence  of  liquid  in  the  chest,  it  may  be  mentioned  that  the 
heart,  if  at  all  displaced,  is  pushed  upward  and  not  towards  the  side  ; 
and  that  the  dulness  of  an  enlarged  liver  extends  higher  up  anteriorly 
than  posteriorly,  while  the  reverse  takes  place  in  a  pleuritic  effusion. 
Moreover,  the  respiration  at  the  lower  portion  of  the  lung  posteriorly, 
although  enfeebled,  is  still  audible. 

Enlargement  of  the  Spleen. — An  enlarged  spleen  is  attended  with 
prominence  and  with  dulness  on  percussion  at  the  lower  part  of  the 
chest  on  the  left  side,  and  might,  therefore,  mislead  into  the  idea  of  a 
pleuritic  efl'usion.  Error  is  prevented  by  attention  to  the  fact  that  the 
dulness  extends  also  downward,  and  towards  the  median  line,  and  is 
much  lower  on  full,  held  inspiration.  Again,  the  heart  is  not  laterally 
displaced,  but  tilted  upward  ;  the  respiration  is  feeble,  but  not  absent ; 
and  the  vocal  vibrations  are  mostly  unimpaired. 

Abscess  in  the  Thoracic  Walls. — This,  too,  leads  to  local  tumefac- 
tion and  fluctuation ;  but  we  can  ascertam  whether  a  fluctuating 
tumor  in  the  intercostal  spaces  communicates  with  the  pleural  cavity 
or  not — whether,  in  other  words,  it  is  or  is  not  the  result  of  an  efl'u- 
sion which  is  pointing  externally — by  watching  how  pressure  and 
the  acts  of  respiration  affect  it.  For  unless  the  diaphragm  has 
become  immovable  from  the  extent  of  the  effusion,  a  bulging  which 
is  in  connection  with  the  pleura  is  diminished  durmg  a  full  inspira- 
tion, and  becomes  more  prominent  when  the  diaphragm  ascends 
in  expiration.  The  swelling,  moreover,  can  be  made  to  disappear  to 
some  extent  by  pressure.  It  is  not  so  with  an  abscess  seated  in  the 
walls  of  the  chest.  It  is  hot  reducible,  and  it  does  not  recede  during 
inspiration. 

Pericardial  Effusion. — An  effusion  into  the  pericardium  induces 
prominence  and  increased  dulness  on  percussion  over  the  region  of 


DISEASES  OF  THE  LUNGS.  363 

the  heart ;  an  effusion  into  the  pleura,  dulness  and  prominence  over 
the  back  as  well  as  over  the  front  of  the  lung.  An  enormously  dis- 
tended pericardial  sac  will,  however,  produce  a  flat  sound  posteriorly, 
and  give  rise  to  signs  of  compression  of  the  lung.  But  in  this  case 
attention  to  the  feeble  impulse  of  the  heart  and  its  muffled  sounds  tell 
us  that  fluid  has  accumulated  in  the  pericardium. 

Hydrothorax. — The  physical  signs  are  the  same  as  those  of  an 
effusion  due  to  inflammation ;  but  as  the  dropsy  results  from  an 
organic  disease  of  the  liver,  heart,  or  kidneys,  the  serum  collects  in 
both  pleural  sacs.  Now,  an  effusion  caused  by  an  inflammation  of 
the  pleura  is  almost  always  one-sided.  Even  where  both  pleurae  are 
filled  with  fluid, — a  rare  condition,  except  in  tubercular  pleurisy, — 
one  is  affected  before  the  other.  This  does  not  happen  in  hydro- 
thorax.  Thus  the  double-sided  effusion,  and  its  usual  association 
with  dropsies  in  other  parts  of  the  body,  are  matters  of  much  signifi- 
cance. Besides,  in  forming  a  diagnosis  of  hydrothorax  we  may  lay 
stress  on  the  absence  of  friction  sounds  ;  on  the  smaller  quantity  of 
fluid  ;  on  the  history  of  the  malady  ;  and  especially  on  the  presence  of 
a  structural  lesion  of  the  liver,  kidneys,  or  heart. 

These,  then,  are  the  diseases  with  which  chronic  pleurisy,  when  it 
produces  dilatation  of  the  chest,  may  be  confounded.  Indeed,  in  view 
of  the  frequency  of  the  operation  of  aspiration  or  of  paracentesis,  it 
is  important  to  know  what  affections  besides  chronic  pleurisy  may 
lead  to  prominence  of  the  chest  and  to  compression  of  the  lung ;  and 
tapping  of  the  chest  has  in  itself  certain  diagnostic  bearings  which 
may  be  here  mentioned.  One  of  these  is  an  albuminous  expectora- 
tion that  follows,  which  may  be  looked  upon  as  a  passing  albuminuria 
due  to  circulatory  disturbances.  It  is  not  an  unfavorable  event ;  on 
the  contrary,  in  cases  in  which  it  happens,  retraction  of  the  thoracic 
parietes  is  less  likely  to  occur.^ 

Diseases  in  which  Retraction  of  the  Chest  occurs. 
Chronic  Pleurisy. — We  may  here  continue  the  description  of 
chronic  pleurisy  in  the  stage  of  absorption,  since  it  is  under  these  cir- 
cumstances that  the  most  marked  retraction  of  the  walls  of  the  chest 
takes  place.  This  shrinking  of  the  thoracic  parietes  is  not  a  sudden, 
but  a  gradual  act,  and  instances -are  therefore  constantly  met  with  in 
which  the  upper  part  of  the  chest  is  flattened  and  the  lower,  owing  to 
its  still  containing  fluid,  bulges.  The  contraction  of  one  side  of  the 
thorax  attains  its  highest  degree  when  the  effusion  in  the  pleura  is 

^  Legroux,  Arch.  Gen.  de  Med.,  Aug.  1873. 


364  MEDICAL  DIAGNOSIS. 

discharged  through  the  chest  walls,  and  external  fistulous  openings 
are  established. 

The  symptoms  in  the  stage  of  retraction  are  those  of  chronic  pleu- 
risy with  dilatation  of  the  chest,  and  present,  therefore,  the  same 
variableness.  But  oedema  of  the  affected  side,  which  is  sometimes  so 
striking  a  symptom  of  chronic  pleurisy  when  the  effusion  is  consider- 
able, is  here  not  noticed.  The  physical  signs  alter  somewhat,  accord- 
ing to  the  presence  or  absence  of  fluid  in  the  pleural  sac.  When  none 
exists,  respiration  is  heard  all  over  the  lung  as  a  feeble  inspiration  with 
prolonged  expiration,  or  as  an  indistinct  blowing ;  and  now  and  then 
a  friction  sound  may  be  caught.  When  the  pleura  still  contains 
liquid,  these  signs  occur  at  the  upper  portion  of  the  chest,  and  a  much 
more  absolute  dulness  on  percussion,  an  absent  voice  and  vocal  frem- 
itus at  the  lower  part  denote  that  fluid  has  there  accumulated.  The 
heart  is  found  either  in  its  normal  position  or  still  displaced.  The 
force  with  which  contraction  takes  place  may  pull  it  over  to  the  side 
on  which  the  shrinking  is  going  on.  Wasting  of  the  muscles  of  the 
shoulder  and  sensory  changes  on  the  affected  side  of  the  chest  have 
been  observed  as  a  result  of  chronic  adhesive  pleurisy.^ 

Now,  it  is  evident  that  chronic  pleurisy,  when  leading  to  retraction 
of  one  side  of  the  chest,  may  be  mistaken  for  affections  like  pulmo- 
nary cancer,  tubercle,  and  chronic  consolidation,  Avhich  also  occasion 
a  flattening  of  the  chest  walls. 

From  cancer  we  distinguish  it  by  the  absence  of  the  pecuhar 
expectoration  and  of  hemorrhage ;  by  the  want  of  signs  of  perfect 
consolidation  ;  and  by  the  dissimilar  history.  We  distinguish  it  from 
tubercle  by  the  diminution  of  the  chest  in  the  latter  not  being  confined 
to  one  side  ;  by  the  physical  signs  indicative  of  deposit  and  softening 
of  the  upper  portion  of  the  lungs  ;  by  the  presence  of  rales ;  by  the 
occurrence  of  hemorrhage  ;  by  the  greater  emaciation ;  and  by  the 
tubercle  bacilli  in  the  sputum. 

Chronic  interstitial  j)neumonia  presents,  on  the  whole,  most  points 
of  resemblance.  But  there  is  this  difference  :  the  shrinking  of  the  side 
in  this  disease  is  less  marked  and  is  confined  to  the  part  involved, — 
usually  the  lower  lobe  of  the  lung.  The  retraction  is  much  more 
general  in  chronic  pleurisy  ;  or  where  it  is  partial,  it  is  the  upper  seg- 
ment of  one  side  of  the  chest  which  is  flattened, — the  lower  is  promi- 
nent, and  sounds  very  dull  on  percussion,  shows  no  change  on  respi- 
ratory percussion,  and  yields  the  ordinary  physical  evidence  of  a  fluid. 
In  the  former  malady  the  blowing  respiration,  or  the  enfeebled  inspi- 

1  Thevenet,  Lyon  Medical,  1894,  No.  5. 


DISEASES  OF  THE  LUNGS.  "  365 

ration  and  prolonged  expiration,  and  the  distinct  voice  are  heard  only- 
over  the  consolidated  lobe  ; .  in  the  other  lobes  the  breathing  is  plainly 
vesicular.  In  chronic  pleurisy  the  same  abnormal  signs,  except  per- 
haps the  increased  voice,  are  either  manifest  over  an  entire  side,  or 
are  perceived  over  the  narrowed  portion  of  the  chest ;  and  at  the 
lower  part  the  respiration,  voice,  and  fremitus  are  abolished. 

In  that  form  of  chronic  pulmonary  induration  attended  commonly 
with  dilatation  of  the  bronchial  tubes,  to  which  the  name  of  cirrhosis 
of  the  lung,^  or  fibroid  phthisis,  has  been  given,  the  flattening  of  the 
affected  side  is  as  obvious  as  it  is  in  pleurisy.  In  truth,  the  two  dis- 
orders bear  a  strong  relation  to  each  other.  The  increased  formation 
of  connective  tissue  in  the  jDleuritic  adhesions  passes  on  into  the  lung, 
— occasioning  an  interstitial  pneumonia, — though  the  fibroid  change 
oftener  begins  in  the  lung ;  as  this  progresses  and  the  lung  shrinks, 
bronchial  dilatations  usually  follow.  We  distinguish  cirrhosis  of  the 
lung  by  the  copious  and  peculiar  sputum  ;  by  the  rales  ;  by  tlie  harsh 
or  bronchial  or  feeble  respiration  ;  by  the  dulness  on  percussion  with 
an  occasional  tympanitic  note ;  by  the  marked  resistance  of  the  chest 
walls  ;  by  the  increased  vocal  resonance ;  by  the  narrowing  of  the 
intercostal  spaces ;  and  by  the  displaced  or  undiscernible  apex  beat. 
The  heart  may  be  drawn  over  to  the  diseased  side,  if  this  be  the 
right  side.  When  the  malady  is  left-sided,  further  signs  of  the  com- 
plaint are  that  in  the  second  intercostal  space  to  the  left  of  the  ster- 
num a  double  beat  of  the  pulmonary  artery  is  perceptible.  Which- 
ever side  is  diseased  shows  the  diaphragm  greatly  displaced  upward, 
and  a  marked  vesicular  resonance  in  a  line  along  the  edge  of  the 
sternum  caused  by  the  overlapping  of  the  healthy  lung,  and  in  strong 
contrast  with  the  line  of  dulness  of  the  cirrhosed  organ.^  The  affec- 
tion is  a  chronic  one,  and  unattended  with  fever  or  laryngeal  symp- 
toms. Loss  of  flesh  and  of  strength  is  very  gradual,  and  night-sweats 
are  slight  or  inconstant.  Dilatation,  or  hypertrophy  with  dilatation, 
of  the  right  side  of  the  heart,  and  dropsy,  are  not  infrequent,  and 
haemoptysis  is  still  oftener  met  with.  It  is  a  mistake  to  suppose  that 
it  occurs  only  when  tubercles  are  present,  or  in  what  is  called  the 
bacillary  variety  of  fibroid  phthisis.^ 

The  disease  has  among  its  causes  the  inhalation  of  fine  particles, 
such  as  of  steel,  of  coal-dust,  of  iron-dust,  of  cotton.  It  may  have 
an  obscure  beginning,  or  it  may  clearly  date  from  an  acute  pneu- 

^  Corrigan,  Dublin  Quarterly  Journal,  vol.  xiii. 
^  Nothnagel,  Sammlung  Klinischer  Vortriige,  1874. 
^  Sir  Andrew  Clark,  Lancet,  July,  1892. 
23 


366  ■  MEDICAL  DIAGNOSIS. 

monia,  especially  an  acute  or  a  subacute  broncho-pneumonia,  or  a 
plastic  pleurisy.  It  may  become  complicated  with  tubercle,  and  then 
tubercle  bacilli  are  found  in  the  sputum.  The  fibroid  condition  m  old 
tubercular  lungs  or  around  cavities  is  an  evidence  of  a  disposition 
towards  healing,  a  local  fibroid  change,  and  is  not  fibroid  phthisis. 
Pulmonary  cirrhosis  often  proves  fatal  from  an  acute  affection,  a 
pneumonia  or  a  broncho-pneumonia,  of  the  previously  healthy  lung. 
In  rare  instances  it  is  double.^  Its  association  with  chronic  malaria  is 
especially  dwelt  on  by  Laveran.- 

The  connection  of  pleurisy  with  the  cirrhotic  lung  has  just  been 
mentioned ;  and,  though  the  origin  of  mterstitial  pneumonia  from  in- 
vasion through  the  pleura  is  in  dispute,  I  hold  the  view  to  be  correct. 
We  must,  however,  not  forget  that  primitive  dry,  ov  jjlastic,  pleurisy 
is  found  also  under  other  circumstances,  and  may  give  rise  to  retrac- 
tion of  the  chest.  Firm  fibrous  bands  may  result  from  organization 
in  the  pleura  after  a  dry  pleurisy,  or  after  absorption  of  the  effusion ; 
plastic  pleurisy  may  be  of  tuberculous  origin.  It  is  then  usually 
double-sided.  Osier  ^  mentions  some  remarkable  vasomotor  phe- 
nomena when  these  primitive  dry  pleurisies  affect  the  apex  and 
probably  involve  the  first  thoracic  ganglion,  such  as  flushing  or 
sweating  of  one  cheek  or  dilatation  of  the  pupU. 

A  collapsed  state  of  the  lung,  resulting  from  a  plug  of  mucus  in 
the  bronchial  tubes,  may  yield  the  manifestations  of  chronic  pleurisy 
with  partial  retraction.  No  signs  distinguish  such  cases,  except  the 
more  limited  depression ;  the  absence  of  any  disease  above  the  flat- 
tened spot ;  the  want  of  friction  sound  and  of  tenderness  on  press- 
ure ;  and  the  rapid  disappearance  of  the  physical  phenomena  after 
an  effort  of  coughing  has  removed  the  obstruction.^ 

Where  exieYnal  fistulous  openings  exist,  the  shrinkmg  of  the  side, 
as  already  stated,  is  carried  to  the  highest  degree.  These  fistulae, 
whether  produced  artificially  or  by  nature,  may  persist  for  months  or 
years,  and  keep  on  dischargmg  offensive,  purulent  matter.  The 
patient  emaciates  under  this  contmued  drain,  yet  not  so  quickly  as 
might  be  imagined.  The  cough  is  not  ordinarily  accompanied  by 
much  expectoration.  Every  now  and  then,  however,  a  quantity  of 
fetid,  purulent  sputum  is  discharged  for  days.  It  is  then  very  likely, 
as  Traube  has  observed,  that  the  pus  has  softened  part  of  the  pulmo- 

^  McCollom,  New  York  State  Medical  Association,  1885. 
'  Bull,  et  Mem.  de  la  Soc.  Med.  des  Hop.  de  Paris,  1894.  p.  233. 
^  Practice  of  Medicine. 

*  An  instance  of  the  kind  is  related  by  Professor  William  Pepper  the  elder  in 
the  American  Journal  of  the  Medical  Sciences  for  April,  1852. 


DISEASES  OF  THE  HEART.  367 

nary  pleura  sufficiently  to  soak  through  the  lung  into  a  bronchial 
tube.  It  seems  certain  that  it  is  not  the  liquid  in  the  pleura  which  is 
being  voided  through  a  distinct  perforation  of  the  pulmonary  tissue, 
for  the  physical  signs  of  pneumothorax  are  absent.  The  clubbing  of 
the  nails  is  often  extremely  marked,  and  may  exist  to  an  extent  far 
greater  than  in  phtliisis.  The  nail  is  rounded  and  bluish,  and  the 
whole  end  of  the  finger  looks  enlarged.  This  appearance  is  even 
more  striking  than  the  curve  of  the  nail.  The  nails  and  last  joints  of 
the  toes  show  the  same  alteration. 

The  fistulous  opening  is  situated  ordinarily  in  the  intercostal 
space  below  the  nipple.  It  may,  however,  be  seated  at  the  back  of 
the  chest,  and  communicate  by  a  tortuous  sinus  with  the  intestme 
and  other  abdominal  viscera.  A  pleuro-bronchial  fistula  may  form ; 
if  the  opening  pass  into  the  lung,  the  physical  evidences  of  pneumo- 
thorax are  present,  but  the  side  is  still  retracted,  and  striking  the 
chest  elicits  a  mixture  of  a  dull  and  a  tympanitic  sound.  Where 
merely  an  external  opening  exists,  no  signs  of  pneumothorax  occur, 
because  no  air  finds  its  way  into  the  pleural  cavity. 

A  fistulous  opening  into  the  pleura  is  not  difficult  of  diagnosis.  It 
is  easy  to  establish  the  fact  that  the  fistula  is  not  simply  produced  by 
caries  of  the  rib  ;  for  a  probe  may  be  run  into  the  chest  for  two,  three, 
or  four  inches. 

SECTION  II. 

DISEASES    OF    THE    HEART. 

The  heart  is  kept  from  rolling  about  in  the  chest  by  the  great 
vessels  which  spring  from  its  base,  and  by  the  attachment  to  the  dia- 
phragm of  its  membranous  covering,— the  pericardium.  It  lies 
obliquely  in  this  membrane,  with  its  long  axis  directed  downward 
and  towards  the  left.  Its  base  points  backward  and  upward  towards 
the  right  shoulder ;  its  under  side  rests  upon  the  central  tendon  of  the 
diaphragm.  The  valves  all  lie  in  close  proximity  to  one  another,  and 
within  a  space  of  less  than  an  inch  square. 

The  relations  the  different  parts  of  the  organ  bear  to  the  chest 
walls  are  as  follows :  The  auricles  are  on  a  line  with  the  third  costal 
cartilages ;  the  right  auricle  extends  across  the  sternum  to  the  right 
of  the  chest.  The  right  ventricle  is  placed  partly  under  the  sternum, 
and  partly  to  the  left  of  it.  Its  inferior  border  is  on  a  level  with  the 
sixth  cartilage.  The  left  ventricle  lies  within  the  nipple,  between  the 
thu:d  and  fifth  intercostal  spaces.  The  apex  is  seated  between  the 
cartilages  of  the  fifth  and  sixth  ribs,  to  the  inner  side  of,  and  from  an 


368 


MEDICAL  DIAGNOSIS. 


inch  and  a  half  to  two  inches  below,  the  left  nipple.  The  base  of  the 
heart  corresponds  posteriorly  to  the  sixth  and  seventh  dorsal  verte- 
brae, from  which  it  is  separated  by  the  aorta  and  oesophagus.  The 
greater  portion  of  the  anterior  surface  of  the  heart  is  removed  from 
the  thoracic  walls  of  the  lungs.  The  right  lung  extends  to  the 
middle  of  the  sternum.  The  left  lung  spreads  out  as  far  as  the 
fourth  cartilage,  and  covers  the  whole  of  the  left  ventricle,  except  the 
apex.  The  part  of  the  heart  which  remains  exposed  consists  thus 
mainly  of  the  lower  portion  of  the  right  ventricle  ;  it  presents  the 
shape  of  a  rough  triangle. 

Fig.  43. 


Topography  of  the  heart.    The  relations  of  each  portion  of  the  heart  to  the  walls  of  the  chest  are 
shown.    The  dotted  lines  mark  the  lungs.    The  figure  is  based  upon  several  careful  dissections. 


At  the  left  border  of  the  sternum,  on  a  level  with  the  third  inter- 
costal space,  lies  the  mitral  valve,  and  in  front  of  this,  more  directly 
under  the  sternum,  and  but  a  few  lines  lower,  the  tricuspid  valve. 
The  pulmonary  orifice  is  seated  opposite  the  junction  of  the  cartilage 
of  the  third  rib  with  the.  left  edge  of  the  sternum.  Near  it,  very 
slightly  lower,  but  placed  more  obliquely,  are  the  aortic  valves.  The 
aorta  then  proceeds  from  left  to  right,  and  ascends  to  the  upper 
border  on  the  second  costal  cartilage  on  the  right  side  ;  thence  it 
crosses,  under  the  sternum  and  in  front  of  the  trachea,  to  the  left 


DISEASES  OF  THE  HEART.  369 

side.  The  pulmonary  artery  is  found  in  the  second  intercostal  space 
on  the  left  side,  enclosed  in  the  pericardium,  and  passes  to  the  carti- 
lage of  the  second  rDD,  where  it  bifurcates. 

The  size  of  the  heart  is  about  that  of  the  closed  fist.  Its  mean 
weight  in  adults  is  between  eight  and  nine  ounces.  Only  in  ver}^ 
large  persons  does  it  exceed  this. 

The  organ  exhibits,  when  in  action,  a  wonderfully  perfect  mech- 
anism and  regularity  of  movement.  Its  cavities  contract  on  both 
sides  at  the  same  time,  and  distend  on  both  sides  at  the  same  time. 
It  then  rests  for  a  short  period.  The  contraction  of  the  ventricles 
occasions  the  impulse  which  is  seen  and  felt  in  the  fifth  intercostal 
space.  While  the  blood  is  flowing  in  and  out  of  the  heart,  the  valves 
are  kept  in  constant  motion.  Their  play  makes  itself  known  by  two 
distinct  sounds  of  unequal  length,  which  are  produced  mainly  by 
their  opening  and  closing. 

The  first  sound,  long  and  dull,  is  caused  by  the  forcible  closure 
of  the  valves  at  the  auriculo-ventricular  openings.  Yet  it  is  not  a 
purely  valvular  sound.  The  stroke  of  the  heart  against  the  walls  of 
the  chest,  the  muscular  contraction  itself,  and  the  flow  of  blood  into 
the  aorta  and  the  pulmonary  artery  aid  in  its  formation.  The  first 
sound  corresponds,  therefore,  to  the  closure  of  the  auriculo-ventricu- 
lar valves,  to  the  impulse  of  the  heart,  to  the  opening  of  the  valves 
at  the  orifice  of  the  aorta  and  of  the  pulmonary  artery,  and  to  the 
passage  of  blood  along  the  arteries.  The  second  sound  is  short, 
abrupt,  and  ringing.  It  results  from  the  sudden  closure  of  the  semi- 
lunar valves.  During  its  occurrence  the  blood  rushes  through  the 
opened  mitral  and  tricuspid  valves,  and  dilates  the  ventricles. 

Examination  of  the  Heart  by  the  Different  Methods  of 
Physical  Diagnosis. 

Before  proceeding  to  examine  the  heart,  we  inquire  into  the  his- 
tory of  the  case,  and  into  such  symptoms  as  the  expression  of  the 
face,  the  appearance  of  the  eye,  the  condition  of  the  capillary  circu- 
lation, the  presence  or  absence  of  dropsical  swellings  and  of  cough, 
the  state  of  the  breathing,  the  character  of  the  pulse,  and  the  fre- 
quency and  violence  of  the  palpitations.  The  cardiac  region  is  then 
explored  by  the  eye  and  by  the  hand ;  the  size  of  the  organ  is  esti- 
mated by  percussion,  and,  lastly,  its  sounds  are  studied  by  the  steth- 
oscope. These  different  methods  are  most  conveniently  practised 
when  the  patient  is  in  an  easy  position,  leaning  back  in  a  chair  or 
propped  up  with  pillows  in  bed.     To  examine  them  more  in  detail : 


370  MEDICAL   DIAGNOSIS. 

INSPECTION. 

Inspection  detects  on  the  chest  of  some  healthy  persons  a  shght 
protrusion  over  the  seat  of  the  heart ;  yet  this  is  far  from  being  con- 
stant or  even  the  general  rule.  When  the  heart  is  hypertrophied,  or 
v^hen  fluid  has  accumulated  in  the  pericardium,  we  perceive  a  marked 
prominence  in  the  praecordial  region.  A  depression  at  the  low^er  part 
of  this  region  may  be  natural ;  a  very  evident  depression  is  almost 
always  the  result  of  an  attack  of  pericardial  inflammation. 

Yet  neither  prominence  nor  depression  is  a  very  important  sign. 
One  much  more  so,  which  inspection  shows,  is  the  impulse,  of  the 
heart.  This  is  seen  where  the  apex  beats  against  the  walls  of  the 
chest :  between  the  fifth  and  sixth  rilDS,  about  an  inch  inward  from 
the  nipple  and  two  inches  downward.  It  is  for  the  most  part  confined 
to  this  point,  and  appears  as  a  brief  raising  of  the  integument,  occur- 
ring with  great  regularity  of  succession.  In  lean  persons  it  is  very 
distinct ;  in  fat  persons  it  is  generally  not  at  all  perceptible.  Its  seat, 
even  in  those  who  are  in  perfect  health,  is  not  always  exactly  the 
same.  It  is  changed  by  different  positions,  and  by  the  distention  of 
the  stomach  after  a  full  meal  or  by  flatulence.  It  is  most  modified  by 
the  acts  of  respiration.  During  a  long-drawn  inspiration  the  heart 
descends  somewhat  and  the  expanded  lung  sweeps  it  inward,  and  the 
impulse  becomes  discernible  in  the  epigastrium.  During  a  fixed  expi- 
ration the  beat  moves  upward,  and  appears  more  extended  and 
weightier.  The  changes  produced  in  its  situation  by  disease,  both 
thoracic  and  abdominal,  are  many.  It  is  tilted  upward  and  outward 
by  the  left  lobe  of  an  enlarged  liver.  It  is  displaced  by  various  affec- 
tions of  the  lungs  and  pleura.  It  is  forced  up  by  a  pericardial  effu- 
sion. It  is  visible  lower  down  and  over  a  larger  surface  in  enlarge- 
ments of  the  heart ;  but  even  then  it  is  most  distinct  at  the  apex. 
The  apex  beat  hes  without  the  line  of  the  nipple  in  most  children  up 
to  the  fourth  year.^ 

The  alterations  in  the  character  and  force  of  the  impulse  are  as 
diversified  as  those  of  its  seat.  But  they  are  more  readily  appre- 
ciated by  the  hand  than  by  the  eye. 

PALPATION. 
The  extent  and  force  of  the  beat  are  changed  in  a  number  of  car- 
diac affections,  both  functional  and  organic.     Both  are  temporarily 
increased  by  powerful  excitement ;  both  are  permanently  augmented 

^  J.  Mitchell  Bruce,  Enlargement  of  the  Heart,  in  Keating' s  Cyclopedia  of  the 
Diseases  of  Children,  vol.  ii. 


DISEASES  OF  THE  HEART.  371 

by  hypertrophy.  In  dilatation  and  pericardial  effusion,  the  extent 
over  which  the  stroke  is  felt  is  greater  than  in  health  ;  but  the  impulse 
is  feeble,  and  in  the  latter  disease  irregular  and  wavy.  Softening  of 
the  texture  of  the  heart,  diseases  of  the  brain, 'some  morbid  states  of 
the  blood,  many  infective  fevers,  and  a  low  condition  of  the  system 
will  also  enfeeble  the  beat. 

The  hand,  when  laid  on  the  preecordial  region,  perceives  at  times 
two  impulses.  This  double  impulse  is  often  recognizable  in  health, 
especially  in  thin  persons.  It  becomes  still  more  evident  in  hyper- 
trophy with  dilatation  of  the  ventricles.  One  of  the  beats  is  systolic ; 
the  other  corresponds  to  the  diastole.  Bouillaud  cites  examples  in 
which  the  diastolic  stroke  was  double. 

All  these  modifications  of  the  impulse  stand  in  direct  connection 
with  the  action  of  the  ventricles.  The  auricles,  save  in  some  rare 
instances  in  which  they  are  dilated  and  their  walls  thickened,  give 
rise  to  no  perceptible  movement  in  the  chest  wall. 

The  sounds  of  the  heart  can  be  analyzed  by  placing  the  hand  over 
the  cardiac  region.  They  will  be  felt,  the  one  as  a  long  and  dull,  the 
other  as  a  short  and  distinct,  vibration.  The  motion  is  due  to  the 
play  of  the  valves,  and  disappears  with  their  destruction.  The  fingers 
appHed  over  the  heart  perceive  at  times  a  peculiar  thrill,  or  a  rulDbing 
movement.  The  first — called  by  Laennec,  from  its  resemblance  to 
the  purr  of  a  cat,  the  purring  tremor — is  nearly  always  indicative  of 
a  valvular  lesion,  especially  of  mitral  obstruction.  The  second  is 
caused  by  the  to-and-fro  motion  of  a  roughened  pericardium. 

PERCUSSION. 

Percussion  affords  the  readiest  means  of  judging  of  the  size  of  the 
heart.  The  patient  is  placed  in  a  recumbent  position ;  then,  by  a 
series  of  moderately  strong  taps,  we  proceed  downward  from  near 
the  middle  of  the  left  clavicle,  until  a  dull  sound,  accompanied  by 
decided  resistance,  tells  that  we  are  striking  over  a  solid  organ.  The 
point  at  which  this  dull  sound  begins  is  over,  or  immediately  at  the 
lower  border  of,  the  fourth  cartilage.  It  corresponds  to  the  upper 
limit  of  the  portion  of  the  heart  which  is  left  uncovered  by  the 
lung. 

The  superior  border  of  the  dulness  having  been  thus  ascertained, 
we  next  percuss  on  the  right  side  of  the  sternum,  on  about  a  level 
with  the  fifth  rib,  and  progress  across  the  bone.  At,  or  very  near  to, 
its  left  edge  we  find  marked  resistance  and  a  duller  sound.  Here  we 
draw  our  second  line,  and  continue  to  strike  straight  across  the  cardiac 
region  up  to  the  point  at  which  a  clear,  full  note  demonstrates  that 


372  MEDICAL  DIAGNOSIS. 

the  pulmonary  tissue  is  resounding.  This  determines  the  transverse 
diameter  of  the  heart, — at  least  so  far  as  it  can  be  mapped  out  on  the 
chest.  The  apex  of  the  organ  and  its  inferior  surface  remain  to  be 
fixed.  The  first  is  rea'dily  done  by  advancing  in  an  oblique  direction 
from  the  already  ascertained  right  border.  But  we  can  save  ourselves 
this  trouble  by  feeling  for  the  impulse  or  by  listening  for  it  with  a 
stethoscope. 

The  inferior'  surface  can  be  circumscribed  by  prolonging  the  line 
of  the  dulness  on  percussion  of  the  upper  border  of  the  liver,  and 
then  judging  by  the  greater  amount  of  resistance  and  the  fall  in  pitch 
that  the  heart  has  been  reached.  The  dulness  eHcited  by  percussing 
the  cardiac  region  is  not  so  absolute  as  that  of  the  liver  or  of  some 
other  solids.  It  is  mixed  with  the  sound  of  the  lung-tissue,  or  with 
the  resonance  of  the  sternum.  Nor  is  it  a  representation  of  the  size 
of  the  entire  organ.  It  simply  portrays  the  more  superficial  portion, 
which  is  uncovered  by  the  lungs. 

In  women  it  is  particularly  difficult  to  define  these  limits.  It  can 
be  done  only  by  having  the  mammary  gland  drawn  to  one  side  while 
percussing.  It  is  equally  difficult  in  children,  as  the  space  over  which 
the  dulness  is  perceived  is  very  small.  In  adults  the  dulness  ordi- 
narily spreads  over  two,  or  nearly  two,  intercostal  spaces.  Its  trans- 
verse diameter  in  a  grown  person  of  medium  size  is  about  two  inches 
and  a  half.  In  tall,  broad-chested  men  it  is  upward  of  three  inches.. 
Such,  at  all  events,  is  the  result  of  measurements  I  have  made. 

The  range  of  the  dulness  is  changed  by  a  number  of  causes, 
physiological  as  well  as  pathological,  A  full  inspiration  alters  it 
materially,  by  bringing  the  lung  down  over  the  heart,  and  by  dis- 
placing the  organ  itself.  The  upper  border  of  the  percussion  dulness 
shifts  to  the  extent  of  an  intercostal  space.  Below  the  nipple,  between 
the  fifth  and  sixth  ribs,  the  sound  becomes  clear ;  but  over  the  dis- 
lodged lower  part  of  the  heart,  the  beat  of  which  is  distinctly  seen 
under  the  cartilages  of  the  ribs,  at  a  point  varying  from  three-fourths 
of  an  inch  to  one  and  a  fourth  inches  from  the  median  line,  there 
is  dulness  with  resistance  to  the  finger.  A  full  expiration  produces 
converse  phenomena.  It  enlarges  the  boundaries,  especially  in  an 
upward  and  transverse  direction.  The  dulness  reaches  nearly,  or 
even  entirely,  across  the  sternum.  Auscultatory  percussion  enables 
us  to  fix  the  percussion  limits  more  closely.  Sansom's  pleximeter 
also  conduces  to  greater  acuracy  in  cardiac  percussion  ;  ^  so  does  the 
phonendoscope.     The  absolute  size  of  the  heart  is  best  determined 

^  See  paper  by  William  Ewart,  Lancet,  Aug.  1891. 


DISEASES  OF  THE  HEART.  373 

by  the  Roentgen  rays ;  the  fluoroscope  makes  very  clear  the  changes 
in  size  and  shape  produced  by  respiratory  and  other  movements. 

The  area  of  dulness  is  diminished  in  emphysema.  It  is  increased 
by  a  shrinking  of  the  left  lung,  and  by  diseases  of  the  heart  and  of  its 
membranes.  Prominent  among  these  are  hypertrophy,  dilatation,  and 
an  effusion  into  the  pericardial  sac. 

.     AUSCULTATION. 

The  sounds  of  the  heart  are  audible  at  all  parts  of  the  praecordial 
region,  but  not  everywhere  with  equal  distinctness.  The  first,  the 
systolic  sound,  being  more  ventricular  in  origin,  is  best  heard  over  the 
lower  part  of  the  heart ;  the  second,  the  diastolic  sound,  is  valvular 
and  best  defined  at  the  base. 

Each  of  the  valves  forms  a  separate  sound,  or  at  least  a  portion  of 
one.  Now,  experience  teaches  that  there  are  points  at  which  the 
sounds  of  the  several  parts  of  the  heart  may  be  isolated.  Some  of 
these  points  accord  with  the  anatomical  seat  of  the  valves  ;  others  do 
not.  None  do  so  very  closely  ;  and  the  proximity  of  the  valves  to  one 
another  is  such  as  to  make  it  desirable  that  the  localities  selected  for 
listening  to  them  should  be  some  distance  apart. 

Clinical  observation  sanctions  the  following:  the  sounds  of  the 
aorta  are  to  be  studied  at  the  right  edge  of  the  sternum,  in  the  second 
intercostal  space ;  from  there  the  stethoscope  may  be  carried  to  the 
second  costal  cartilage  of  the  right  side,  the  "  aortic  cartilage,"  and 
down  to  the  left  edge  of  the  sternum  opposite  the  third  intercostal 
space, — that  is,  not  far  from  the  seat  of  the  aortic  valves.  The  pul- 
monary orifice  lies  very  close  to  them  :  but  the  artery  itself  ascends  to 
the  second  costal  cartilage  on  the  left  side.  Its  sound  may  be  iso- 
lated in  the  second  intercostal  space,  near  the  left  edge  of  the  sternum. 
The  mitral  is  listened  to  immediately  above  the  beat  of  the  apex.  The 
sounds  of  the  tricuspid  and  of  the  right  ventricle  may  be  sought  for  in 
the  vicinity  of  and  somewhat  above  the  ensiform  cartilage. 

Both  sounds  are  discerned  at  each  of  these  points.  But  the  same 
sound  varies  in  different  situations.  The  first  sound  over  the  left 
ventricle  near  the  apex  of  the  heart  is  dull,  heavy,  and  prolonged ; 
that  over  the  right  ventricle  is  clearer,  shorter,  and  of  higher  pitch. . 
The  second  sound  heard  there  p'resents  no  constant  and  appreciable 
variance  from  that  over  the  left  ventricle ;  yet  it  is  less  ringing  and 
distinct  than  the  second  sound  of  the  pulmonary  artery  and  aorta. 
Even  these  two  are  not  precisely  alike.  The  second  sound  of  the 
latter,  when  compared  with  that  of  the  former,  is  found  to  be  sharper 
and   more   accentuated.     The  first   sound,  however,  does  not  differ 


374 


MEDICAL   DIAGNOSIS. 


materially  from  that  of  the  pulmonary  artery.  But  the  first  sound  of 
both  does  differ  most  materially  from  that  over  the  ventricles.  Com- 
pared with  the  first  sound  over  the  right  ventricle,  the  first  sound  of 
the  pulmonary  artery  is  much  duller,  more  indistinct  and  like  a  vibra- 
tion, and  not  of  so  high  a  pitch.  Compared  with  the  first  sound  at 
the  apex,  the  first  sound  of  the  aorta  lacks  the  weighty,  prolonged 
character  which  belongs  to  the  ventricular  sound. 

Fig.  44. 


Aorlic  n/O'Zves 


'i<  Inion  ary  arter^y  vO'lves 


Diagram  showing  the  points  at  which  the  separate  valves  maj-  be  listened  to. 


The  sounds  just  considered  undergo  various  modifications,  both  in 
health  and  in  disease.  They  may  be  audDDle  over  a  larger  space  of  the 
chest  than  usual ;  they  may  be  changed  in  character  and  in  rhythm. 
Their  transmission  over  a  larger  space  is  an  unimportant  sign.  They 
are  undoubtedly  perceived  over  a  more  extended  surface  when  the 
heart  is  enlarged,  or  when  the  surrounding  tissues  are  condensed. 


DISEASES  OF  THE  HEART.  375 

During  a  full  inspiration,  the  sounds  at  the  interspace  between  the 
second  and  third  costal  cartilages  on  the  left  side  disappear  almost 
entirely,  and  become  faint  at  the  aortic  cartilage.  The  first  sound  at 
the  apex  lessens  also  very  much  in  distinctness,  but  it  is  better  heard 
at  a  new  point  of  impulse,  visible  towards  the  median  line  and  just 
below  the  cartilag-es  of  the  ribs.  During  a  full  expiration,  the  extent 
over  which  the  heart-sounds  are  perceived  is  increased. 

The  sounds  grow  in  loudness  in  any  functional  disturbance  of  the 
heart.  When  the  organ  is  palpitating  violently  under  strong  nervous 
excitement,  they  may  become  short  and  sharp,  and  sometimes  so  loud 
and  ringing  as  to  be  audible  to  the  by-standers.  They  are  often  per- 
nianently  louder  than  in  health,  and  are  shorter  and  more  clearly 
defined  when  the  walls  of  the  heart  are  thinned.  This  is  particularly 
the  case  with  the  first  sound.  When  the  walls  of  the  heart  "are  thick, 
the  first  sound  over  the  hypertrophied  portion  is  apt  to  be  dull  and 
prolonged.  The  first  sound  is  weakened  if  the  structure  of  the  heart 
be  softened  :  hence  it  is  feeble  in  some  low  fevers,  and  in  fatty  degen- 
eration of  the  organ.  It  is  also  less  distinct  when  there  is  a  want  of 
tone  in  the  muscle,  or  when  the  mitral  and  tricuspid  valves  are 
thickened. 

To  determine  whether  a  dull  first  sound  at  the  apex  be  due  to  an 
injured  mitral  valve,  or  to  an  alteration  of  the  muscular  power  of  the 
heart,  Flint  advises  to  place  the  stethoscope  over  the  apex  of  the 
heart,  and  then  on  the  outside  of  the  left  nipple  to  isolate  the  element 
of  impulsion,  which  unites  with  the  valvular  element  to  form  the 
complex  first  sound.  If  there  be  a  marked  impulse  over  the  apex, 
but  if  by  means  of  the  stethoscope  placed  to  the  left  we  perceive  no 
sound  which  possesses  a  valvular  character,  or  hear  a  sound  only 
faintly  valvular,  we  infer  that  the  mitral  valves  are  damaged. 

The  second  sound  is  not  so  liable  to  be  changed  as  the  first.  It  is 
rendered  somewhat  duller  by  a  thickening  of  the  semilunar  valves ; 
on  the  other  hand,  it  is  more  ringing  when  they  are  thin,  and  in  great 
functional  excitement  of  the  heart,  and  in  altered  blood  conditions,  as 
in  lithsemia  or  in  gout.  The  sound,  indeed,  always  becomes  more 
distinctly  accentuated  if  the  column  of  blood  closes  the  valves  forci- 
bly. This  occurs  not  infrequently  in  hypertrophy  of  the  ventricles, 
especially  the  left,  and  in  the  increased  tension  of  the  vessels  in  con- 
tracted kidney  and  in  arteriosclerosis ;  it  affects  the  second  aortic 
sound.  Accentuation  of  the  second  sound  also  takes  place  where  a 
decided  obstruction  exists  to  the  passage  of  blood  through  the  lungs, 
and  in  mitral  valvular  disease.  In  the  latter  conditions  it  is  over  the 
pulmonary  artery  alone  that  this  accentuated  second  sound  is  audible. 


376  MEDICAL  DIAiG^NOSIS. 

Both  the  sounds  are  occasionally  obscure.  This  happens  when 
fluid  has  accumulated  in  the  pericardium.  The  sounds  may  be 
changed  in  their  relative  proportion  to  each  other,  and  the  pauses 
between  them  be  lengthened  or  shortened,  or  else  the  sounds  may 
intermit  from  time  to  time.  From  this  perverted  rhythm  we  do  not 
derive  any  definite  instruction  as  to  the  condition  causing  it.  It  may 
be  associated  with  organic  disease  or  exist  without  it.  The  same 
may  be  said  of  reduplication  of  the  sounds  of  the  heart.  The  second 
sound  is  the  one  which  is  generally  split.  Yet  both  of  them  may  be 
doubled,  or  one  may  be  doubled  over  one  part  of  the  heart  and  not 
over  another ;  so  that  four  or  three  sounds  are  counted  to  each  beat 
of  the  pulse.  The  cause  of  the  reduplication  is  the  want  of  syn- 
chronous action  of  the  two  sides  of  the  heart.  The  direct  value  for 
diagnosis  'of  the  altered  movement  is  not  great.  Yet  there  is  some 
value  to  be  attached  to  the  changed  rhythm.  Thus,  the  peculiar  alter- 
ation of  the  sounds,  which  causes  us  to  hear  three  sounds  during  the 
action  of  the  heart,  two  of  them  in  the  diastole,  producing  the  rhythm 
that  has  been  likened  to  the  gallop  of  a  horse,  is  often  found  in  con- 
tracted kidney  and  in  arteriosclerosis.  It  is  particularly  heard  over 
the  mitral  and  the  tricuspid  region.  Fraentzel  ^  has  noted  the  frequent 
occurrence  of  this  gallop  rhythm  in  typhoid  fever  and  in  croupous 
pneumonia,  and  looks  upon  it  as  a  sign  of  grave  cardiac  weakness  ; 
it  is  also  a  sign  of  serious  import  in  chronic  Bright's  disease. 

Such,  then,  are  the  modifications  which  the  healthy  sounds  present. 
At  times  we  meet  with  sounds  which  do  not  in  the  least  resemble 
those  naturally  heard,  and  which  overshadow  them  or  take  their 
place.  They  are  called  murmurs^  and  are  mainly  produced  either 
within  the  heart  or  on  its  surface. 

Those  murmurs  that  are  endocardial  have  a  common  quality :  they 
are  more  or  less  blowing.  Yet  the  sound  is  not  always  of  the  same 
character  or  pitch.  It  may  be  low-toned,  it  may  be  high-pitched;  it 
may  be  soft,  it  may  be  harsh ;  it  may  resemble  the  blowing  of  a  bel- 
lows ;  it  may  be  musical ;  it  may  be  filing,  or  rasping,  or  sawing.  The 
ingenuity  of  every  listener  exerts  itself  in  tracing  a  similarity  to  some 
familiar  noise  ;  but  to  little  practical  purpose.  These  different  sounds 
teach  us  nothing  certain  as  to  their  source.  They  are,  moreover,  not 
at  all  times  the  same  in  the  same  case,  since  the  heart  when  excited 
may  emit  a  sound  different  from  that  which  it  does  when  it,  is  beating 
quietly. 

^  Krankheiten  des  Herzens,  Berlin,  1889  ;  see  also  Cuffer  and  Barbillion,  Arch. 
Gen.  de  Med.,  1887. 


DISEASES  OF  THE  HEART.  ^  377 

A  blowing  sound  originates  in  the  altered  relation  of  the  blood  to 
the  part  over  which  it  moves.  This  general  statement  opens  the  way 
to  the  consideration  of  the  specially  acting  elements,  both  in  the  blood 
and  in  the  heart  itself. 

Usually  a  cardiac  murmur  springs  from  a  change  at  one  of  the 
orifices.  This  may  be  either  a  narrowing  or  a  roughening,  which 
interposes  a  local  obstruction  to  the  flow  of  the  blood ;  or  it  may  be 
an  insufficiency  to  close  the  opening.  In  the  latter  case  the  blood 
regurgitates,  and  a  murmur  is  occasioned  by  the  deviation  of  the 
direction  of  the  current  and  the  establishment  of  another.  This  sub- 
version of  the  course  of  the  circulating  fluid,  added  to  its  increased 
velocity  and  force,  is  the  chief  source  of  those  temporary  blowing 
sounds  not  infrequently  perceived  when  a  heart  is  greatly  excited, 
while  both  its  valvular  apparatus  and  its  muscular  texture  are  healthy. 
Obstruction  to  the  circulation,  with,  perhaps,  altered  position  of  the 
heart,  is  the  cause  of  the  cardiac  murmurs  in  pleurisy  and  in  pneu- 
monia. But  we  meet  often  with  instances  where  none  of  these 
causes  are  present,  and  where  altered  blood  is  the  foundation  of  the 
murmur. 

Thus,  to  sum  up  the  subject,  we  find  murmurs  that  depend  upon 
organic  change,  and  murmurs  that  are  unconnected  with  any  struc- 
tural alteration ;  and  these  inorganic  murmurs  are  due  either  to  an 
unnatural  condition  of  the  blood  or  to  temporarily  perverted  action 
or  position  of  the  heart. 

The  murmurs,  however  caused,  have  different  effects  on  the 
sounds  of  the  heart.  They  either  accompany  the  sound  throughout 
the  whole  or  a  part  of  its  duration,  and  thus  obscure  it,  or  else  they 
take  its  place  and  hinder  it  from  being  generated.  In  time  of  their 
occurrence  they  correspond  to  the  contraction  or  to  the  dilatation  of 
the  heart,  and  therefore  to  the  first  or  to  the  second  sound ;  at  least, 
they  do  so  practically.  •  It  is  true,  they  may  immediately  precede  or 
succeed  either  sound,  or  fill  mainly  the  intervals  of  silence  between 
them,  or  occur  early  or  late  in  the  sound ;  but  attention  to  such 
minute  divisions,  except  in  the  case  of  the  presystolic  murmur,  is  for 
most  purposes  unnecessary.  In  point  of  fact,  it  is  often  difficult 
enough  to  say  whether  the  murmur  we  hear  is  systolic  or  diastolic. 
The  readiest  method  of  judging  of  the  time  of  the  production  of  a 
murmur  is  to  feel  for  the  impulse  while  listening  with  the  stethoscope. 
The  blowing  sound  which  agrees  with  the  beat  of  the  heart  is  sys- 
tolic ;  the  one  just  before  the  systole  is  presystolic ;  the  one  between 
the  beats  is  diastolic. 

When  a  murmur  is  once  established  it  attends  each  motion  of  the 


378  MEDICAL   DIAGNOSIS. 

heart  that  can  give  rise  to  it ;  but  it  is  not  always  equally  perceptible. 
It  may  become  very  faint,  or  disappear  entirely,  by  the  patient  changing 
his  position.  It  is  sometimes  manifest  only  when  the  heart  is  acting 
strongly.  Indeed,  it  always  requires  a  certain  force  and  velocity  in 
the  passage  of  the  blood  to  generate  a  murmur.  Yet  overaction  of 
the  heart  may  be  as  destructive  of  its  distinctness  as  dmimished 
action.  This  is,  however,  a  matter  that,  should  it  be  desirable  for 
diagnosis,  we  can  control  by  the  administration  of  medicines  like 
digitalis,  aconite,  or  veratrum  viride,  pro\aded  their  use  be  not  contra- 
indicated. 

A  murmur  is  sometimes  heard  by  the  patient  himself,  or  is  audible 
before  the  ear  is  placed  over  the  heart.  It  may  be  perceived  as  an 
abrupt  blowing  sound,  apparently  coming  out  of  the  mouth.  I  have 
met  with  a  number  of  such  instances.  The  murmur  is  nearly  always 
systolic. 

Posture  exerts  a  decided  effect  upon  murmurs.  A  blowing  sound 
distinct  in  the  recumbent  position  may  become  very  faint  or  dis- 
appear when  the  patient  stands  erect,  and  the  reverse  holds  good, 
although  less  common ;  ansemic  murmurs  are  thought  to  be  more 
intense  in  the  recumbent  position.^  Pressure,  too,  has  an  influence 
upon  the  abnormal  cardiac  sound  ;  it  notably  augments  it,  and  often 
raises  its  pitch.  Yet  pressing  the  stethoscope  against  the  chest  does 
not  occasion  as  much  alteration  in  endocardial  as  it  does  in  peri- 
cardial sounds. 

A  murmur  may  be  obscured  by  the  respiratory  sound ;  and  the 
natural  sounds  of  the  lungs  may  be  mistaken  for  blowing  sounds  in 
the  heart.  Certainly  the  resemblance  is  often  great ;  but  blunders 
may  be  readily  avoided  by  listening  to  the  heart  while  the  patient 
suspends  his  breathing. 

Ha^^ng  ascertained  positively  the  existence  and  the  time  of  occur- 
rence of  an  endocardial  murmur,  the  next  thing  is  to  determine  its 
exact  seat,  and,  if  possDDle,  its  immediate  cause.  The  seat  of  the 
murmur  is  judged  of  by  the  place  of  its  greatest  intensity,  and  by  the 
relation  this  bears  to  one  of  the  four  points  for  the  clinical  examina- 
tion of  the  heart  above  described.  If  it  be  most  distinct  at  or  near 
the  apex  of  the  heart,  it  is  produced  at  the  mitral  orifice  ;  if  immedi- 
ately above  or  at  the  ensiform  cartilage,  it  is  generated  m  the  right 
ventricle  and  at  the  tricuspid  opening.  If  we  hear  it  most  plainly  at 
the  sternum,  somewhat  towards  its  left  border  on  a  level  with  the 
third  intercostal  space   or  even  the  fourth  rib,  and  with  equal   or 

^  James  H.  Hutchinson,  Amer.  Journ.  Med.  Sci..  April,  1872. 


DISEASES  OF  THE  HEART.  379 

nearly  equal  distinctness  at  the  second  costal  cartilage  on  the  right 
side,  we  are  enabled  to  decide  that  it  is  developed  at  the  origin  of  the 
aorta.  The  pulmonary  artery  is  not  often  the  seat  of  a  murmur. 
When  it  is,  this  is  clearly  perceptible  in  the  second  intercostal  space 
on  the  left  side,  and  extends,  if  the  valves  be  diseased,  to  the  junction 
of  the  third  left  cartilage  with  the  sternum ;  although  we  must  bear  m 
mind  that  occasionally  in  mitral  affections  the  murmur  is  loudest  in 
the  pulmonary  area,  or,  as  Naunyn  has  shown,  not  exactly  over  the 
artery,  but  rather  an  inch  and  a  half  or  more  from  the  left  edge  of 
the  sternum  in  the  second  interspace. 

Any  of  these  situations  may  be  the  site  of  a  distinct  murmur 
occupying  only  one  sound  of  the  heart,  or  bemg  produced  in  both, — 
one  murmur  taking  place  with,  the  other  against,  the  current  of 
blood.  Yet  it  rarely  happens  that  the  murmur  is  strictly  limited  to 
one  of  these  positions  :  it  will  mostly  extend  in  various  directions 
from  its  point  of  intensity,  growing  fainter  and  fainter  as  this  is  left, 
A  blowing  murmur  thus  transmitted  may  drown  the  natural  sounds 
of  the  heart  at  the  parts  not  diseased.  But  when  one  orifice  alone  is 
affected,  we  can  usually  hear  the  sounds  at  the  other  valves.  They 
may  be  obscured,  but  still  they  exist ;  and  it  is  a  vast  aid  when  they 
are  heard,  since  they  set  the  lunits  of  the  disease.  How  important 
is  it,  then,  to  examine  each  portion  of  the  heart  separately,  as  much 
for  the  purpose  of  saying  what  is  not  as  what  is  deranged ! 

If  satisfied  as  to  the  seat  of  the  murmur,  we  naturally  turn  to 
inquire  into  its  origin.  Is  it  caused  by  an  alteration  of  the  valves  ? 
Is  it  unconnected  with  any  appreciable  change  of  structure  in  the 
heart  ?  There  is  nothing  in  the  murmur  itself  which  will  tell  us  posi- 
tively. As  a  rule,  it  is  true  that  a  harsh  murmur  results  from  organic 
disease,  and  a  soft  murmur  is  inorganic ;  but  we  judge  with  much 
more  certainty  by  the  time  of  the  occurrence  of  the  blowing  sound 
and  by  the  accompanying  phenomena.  A  murmur  presystolic  or 
diastolic  is  organic ;  a  systolic  murmur  may  or  may  not  be  organic. 
A  murmur  arising  from  an  impoverished  state  of  the  blood  is  systolic, 
generally  soft,  of  low  pitch,  is  perceived  over  the  base  of  the  heart, 
and  is  accompanied  by  a  humming  sound  in  the  veins  of  the  neck. 
It  may  be  heard  over  the  right  base,  or  on  the  left  side  over  the . 
pulmonary  artery ;  although  Balfour  maintains  that  it  is  not  really 
over  the  pulmonary  artery,  but  about  half  an  inch  or  more  to  the 
left  of  the  pulmonary  area,  and  is  not  an  arterial,  but  an  auricular 
sound. 

Throughout  the  consideration  of  the  endocardial  murmurs,  they 
have  been  treated  as  originating  at  the  seat  of  the  valves.     In  truth, 


380  MEDICAL   DIAGNOSIS. 

it  is  there  that  they  are  formed.  Still,  they  are  occasionally  due  to 
morbid  states  in  the  body  of  the  ventricle,  or  in  the  auricle.  But  in 
either  case  this  is  very  rare.  As  regards  the  auricles,  they  yield  no 
appreciable  sound  in  health,  nor  are  they  in  disease,  except  rarely,  the 
source  either  of  sound  or  of  murmur. 

A  blowing  sound  is  not  of  necessity  limited  to  the  heart :  it  may  be 
transmitted  all  over  the  arterial  system.  Yet  it  would  be  a  great  mis- 
take to  suppose  that  every  murmur  heard  over  the  arteries  is  connected 
with  a  disease  of  the  heart.  It  is  often  but  the  sign  of  impoverished 
blood,  or  a  sound  dependent  upon  local  roughening  or  narrowing  of 
the  tube.  The  latter  may  be  temporarily  produced  by  the  pressure 
of  a  stethoscope. 

Let  us  now  examine  the  sounds  which  originate  on  the  outside  of 
the  heart.  These  pericardial  murmurs  have  all  a  common  source : 
they  all  result  from  irregularities  on  the  membrane.  Like  the  pleura, 
the  smooth  serous  covering  of  the  heart  moves  noiselessly  in  health  ; 
but  when  it  is  roughened  by  a  deposit  of  any  kind,  the  friction  of  its 
surface  gives  rise  to  a  sound  which  may  be  single,  but  which  is  usu- 
ally double.  The  character  of  this  sound  is  variable.  It  may  be  a 
to-and-fro  rubbing  murmur,  or  it  may  be  grazing,  or  scratching,  or 
creaking,  or  whistling,  or  clicking  and  resembling  the  valvular  sounds. 
It  has  but  one  quality  which  is  constant,  and  that  is  its  superficiality. 
By  this  superficiality ;  by  the  strict  limitation  of  the  sound  to  the 
region  of  the  heart ;  by  its  altering  from  time  to  time  its  precise  seat ; 
by  its  greater  extent  and  intensity  when  the  patient  bends  forward ; 
by  its  occasional  increase,  and  even  change  of  character,  on  external 
pressure  ;  by  its  following,  rather  than  occurring  with,  the  movements 
of  the  heart ;  and  by  the  sensation  of  friction  which  it  communicates 
to  the  finger, — we  know  that  the  sound  heard  is  produced  on  the  sur- 
face of  the  heart.  Yet,  in  spite  of  this  array  of  points  of  difference, 
it  is  often  difficult  to  distinguish  a  pericardial  from  an  endocardial 
murmur. 

An  error  not  easy  at  times  to  avoid  is  the  failure  to  discriminate 
between  the  presystolic  apex  murmur,  regarded  as  characteristic  of 
mitral  constriction,  and  a  pericardial  friction  localized  near  the  apex. 
The  only  trustworthy  points  of  distinction  are  that  the  pericardial 
sound  changes  in  its  quality  and  loudness  ;  that  it  is  rendered  stronger 
and  changed  in  pitch  by  .pressure  exerted  with  the  stethoscope,  and 
that  the  second  sound  at  the  left  base  is  unaltered. 

A  friction  sound  is  prone  to  mask  the  natural  sounds  of  the  heart. 
At  times,  although  heard  over  the  cardiac  region,  it  is  not  due  to  in- 
flammation of  the  pericardium.     The  exudation  may  be  on  the  sur- 


DISEASES  OF  THE  HEART.  381 

face  of  the  pleura  adjacent  to  the  pericardium,  and  the  murmurs  be 
caused  solely  by  the  movements  of  the  heart,  with  the  rhythm  of 
which  they  coincide.  Sometimes,  again,  the  sound  heard  in  the  car- 
diac region  is  in  reality  the  rubbing  of  an  inflamed  pleura.  If  any 
doubt  exist,  let  the  patient  be  told  to  suspend  his  breathing.  As  this 
is  stopped,  the  pleural  sound  ceases. 

Such  is  a  brief  description  of  the  different  physical  signs  met  with 
in  examining  the  heart,  both  in  health  and  in  disease.  Their  impor- 
tance for  diagnosis  it  is  difficult  to  overestimate.  A  knowledge  of  the 
physical  signs  is  the  solid  foundation,  without  which  any  structure 
that  may  be  raised  will  soon  tumble  to  pieces. 

The  General  and  Local  Symptoms  of  Diseases  of  the  Heart. 

It  is  not  easy  to  say  what  are  and  what  are  not  the  symptoms 
that  belong  to  diseases  of  the  heart.  There  are  vital  manifestations 
directing  attention  to  the  heart  which  are  not  associated  with  any 
change  in  its  structure  ;  and  most  serious  changes  in  its  structure  may 
occur  without  any  of  these  vital  manifestations.  Yet  we  often  fmd 
a  significant  group  of  symptoms  that  accompany  an  affection  of  the 
heart.  Some  of  these  attest  directly  the  organ  disturbed,  such  as 
pain  in  the  cardiac  region  and  palpitation.  Others  are  the  indirect 
and  more  remote  expressions  of  its  derangement,  such  as  cough, 
dyspnoea,  hemorrhages,  dropsy,  disorders  of  the  brain  and  nervous 
system,  engorgement  of  the  abdominal  viscera,  a  peculiar  state  of  the 
arteries  and  veins,  and  the  aspect  of  the  face.  It  is  unnecessary  to 
do  more  than  mention  some  of  these,  since  several  have  been  already 
described  in  connection  with  pulmonary  complaints,  and  there  is 
nothing  in  the  cough  or  in  the  shortness  of  breath  by  which  we  can 
absolutely  determine  it  to  be  caused  by  a  disease  of  the  heart.  The 
same  with  respect  to  hemorrhage ;  there  is  nothing  characteristic 
about  it.  It  simply  proves  the  efforts  of  the  blood-vessels  to  reheve 
themselves  of  the  strain  which  the  disturbance  in  the  flow  of  blood 
has  put  on  them.  The  capillaries  and  the  smaller  blood-vessels  give 
way  first ;  partly  from  the  reason  just  assigned,  and  partly  from  the 
altered  state  of  their  coats,  a  common  associate  of  cardiac  disease. 
These  hemorrhages  are  prone  to  happen  from  the  bronchial  tubes . 
and  the  lungs,  and  the  blood  is  expectorated  ;  but  they  may  also  take 
place  directly  into  the  pulmonary  tissue,  or  into  or  from  any  part  of 
the  body.  Their  danger  is  in  proportion  to  the  amount,  to  the  impor- 
tance of  the  function  of  the  structures  into  which  the  blood  is  effused, 
and  to  the  possibility  of  its  finding  an  outlet.  The  peril  is  greatest 
when  the  blood  is  poured  into  the  brain. 

24 


382  MEDICAL  DIAGNOSIS. 

Cardiac  Dropsy. — The  dropsy  caused  by  disease  of  the  heart  is 
met  with  in  different  situations :  in  the  cehular  tissues,  in  the  perito- 
neal and  pleural  cavities,  in  the  pericardium,  in  the  ventricles  of  the 
brain  and  under  the  arachnoid,  in  the  air-cells  of  the  lungs, — in  fact, 
in  any  part  where  fluid  can  exude,  and  where  there  is  a  space  which 
can  receive. 

In  anasarca  dependent  upon  a  cardiac  lesion,  the  dropsical  swell- 
ing begins  about  the  ankles  and  feet.  The  accumulation  is  much  in- 
fluenced by  position ;  the  feet  are  more  puffy  towards  evening,  when 
the  patient  has  been  all  day  in  the  erect  posture,  and  least  so  when 
he  gets  up  in  the  morning.  The  dropsy  is  most  constantly  found  to 
be  associated  with  disturbance  in  the  flow  of  the  venous  blood,  and 
therefore  with  disorder  of  the  right  side  of  the  heart,  particularly 
with  a  dilatation  of  the  cavities.  It  may  be  permanent  or  not.  Its 
extent  certainly  does  not  bear  a  constant  relation  to  the  extent  of  the 
cardiac  disease.  It  bears  a  more  constant  relation  to  the  amount  of 
venous  congestion,  and  to  the  impoverishment  of  the  blood. 

Derangement  of  the  Circulation. — Unmistakable  evidence  of 
the  obstruction  to  the  flow  of  blood  through  the  veins  is  afforded  by 
their  prominence  in  different  portions  of  the  body.  This  is  espe- 
cially manifest  in  the  superficial  veins  of  the  neck,  which,  moreover, 
when  the  tricuspid  orifice  is  permanently  open,  exhibit  a  distinct  pul- 
sation with  each  beat  of  the  heart.  The  turgid  condition  of  the 
venous  system  is  rendered  equally  obvious  by  the  livid  tinge  of  the 
skin  and  the  bluish  color  of  the  lip,  and  by  ramifications  of  fine  bluish 
vessels  on  the  surface.  But  the  arterial  system  may  also  be  gorged, 
and  we  may  find  the  capillaries  and  the  smaller  arteries  seemingly 
ready  to  burst.  The  conjunctiva  is  then  highly  injected,  and  the 
cheek  has  a  coarse,  red  look.  This  change  in  the  color  and  appear- 
ance of  the  face,  the  thickening  of  the  eyehds,  and  the  prominent  eye, 
make  up  the  peculiar  physiognomy  of  a  chronic  cardiac  malady.  The 
state  of  the  larger  arteries  is  very  variable,  and  mainly  according  to 
the  nature  of  the  disorder  and  the  condition  of  the  cardiac  walls  and 
of  the  blood-pressure.  The  pulse  may  be  small  and  tense  ;  it  may  be 
full ;  it  may  be  rebounding ;  it  may  be  very  irregular ;  and  it  is  often 
out  of  aU  proportion  to  the  forcible  action  of  the  heart. 

The  derangement  of  the  circulation  of  individual  parts  manifests 
itself  by  special  symptoms.  It  shows  itself  in  the  brain  by  attacks  of 
cerebral  congestion ;  by  vertigo ;  by  violent  headache,  occurring  in 
spells,  or,  less  acute,  in  dull  persistent  ache,  increased  on  exertion, — 
a  form  especially  met  with  in  children.  We  see  evidences  of  the  con- 
gestion of  the  nervous  system  in  the  disturbed  dreams  ;  in  the  sudden 


DISEASES  OF  THE  HEART.  383 

starting  up  from  sleep  ;  in  the  irregular  action  of  certain  muscles  ;  in 
the  spots  which  float  before  the  eye.  It  is  possible  that  the  strange 
sense  of  insecurity  and  the  irritability,  of  which  patients  afflicted  with 
a  cardiac  malady  complain,  are  produced  by  the  same  cause.  At  any 
rate,  whether  produced  thus  or  not,  they  are  remarkable  symptoms. 
There  is  no  disease  which  unnerves  more  than  a  disease  of  the  heart. 
Indeed,  the  mere  fear  of  its  presence  gives  rise  to  restlessness  and 
gloom,  and  breeds  timidity  in  those  who  would  look  any  external 
danger  boldly  in  the  face. 

The  disordered  flow  of  blood  through  the  abdominal  viscera  occa- 
sions organic  changes  and  a  disturbance  of  the  functions  of  the  several 
organs.  Thus,  the  liver  increases  in  size,  or  undergoes  other  altera- 
tions which  interfere  more  or  less  seriously  with  the  elimination  of  the 
bile  ;  or  the  kidneys  no  longer  secrete  as  in  health,  but  become  much 
engorged  and  drain  off  the  albumin  of  the  blood ;  or  the  spleen  sus- 
tains textural  transformations.  These  states  all  tend  to  give  rise  to 
more  and  more  dropsy,  and  hence  to  more  and  more  suffering. 

The  symptoms  which  point  most  directly  to  the  heart  itself  are 
palpitation  and  irregularity  of  action,  and  pain.  These  symptoms 
denote  that  the  function  of  the  organ  is  disturbed,  or  that  its  innerva- 
tion is  in  some  manner  deranged ;  but  they  denote  nothing  more. 
They  are,  therefore,  common  to  functional  derangement  which  occurs 
associated  with  structural  changes  in  the  heart,  and  to  purely  func- 
tional derangement. 

Cardiac  Pain. — Pain  m  or  over  the  heart  is  met  with  in  both 
acute  and  in  chronic  diseases  ;  yet  it  is  not  a  regular  or  well-defined 
symptom  of  either.  When  we  reflect  that  the  heart  may  be  pinched, 
may  be  torn,  without  exciting  any  suffering,  it  will  be  readily  under- 
stood why  its  disorders  do  not  occasion  much  pam.  Indeed,  many  a 
case  of  enormous  enlargement  of  the  heart,  or  of  profound  textural 
alteration  of  its  walls  or  valvular  apparatus,  is  unaccompanied  by 
pain.  Still,  we  meet  with  instances  in  which  distress  at  the  heart  and 
various  uneasy  sensations  are  among  the  more  marked  symptoms  of 
a  chronic  cardiac  lesion ;  and  we  even  find  persons  complaining  of  a 
persistent  pain  in  the  heart,  which  extends  to  the  left  side  of  the  neck 
and  arm,  in  whom  this  symptom  has  preceded  the  signs  of  a  disease 
of  the  heart  or  of  its  great  vessels.  The  greatest  suffering  happens  in 
the  obscure  malady  termed  angina  pectoris. 

Angina  Pectoris. — The  disease  occasions  paroxysms  of  intolerable 
anguish.  These  come  on  suddenly,  and  pass  off  as  suddenly.  Their 
main  feature  is  an  agonizing  pain  in  the  praecordia,  as  if  the  heart 
were  being  firmly  grasped  by  an  invisible  hand,  or  as  if  it  were  being 


384  MEDICAL  DIAGNOSIS. 

torn  to  pieces.  The  pain  is,  however,  not  Hmited  to  the  cardiac  re- 
gion;  it  radiates  in  various  directions,  shooting  to  the  back,  to  the 
neck,  and  especially  down  the  left  arm.  But  this  is  not  all :  worse 
than  the  pain  are  the  intense  anxiety  and  the  feeling  of  impending 
death.  The  heart  palpitates  during  the  fit.  Yet,  if  we  judge  by  the 
character  of  the  pulse,  its  movements  are  not  always  materially  dis- 
turbed;  for  this  may  be  but  little  altered,  and  regular;  very  gen- 
erally the  arterial  tension  is  high.  Again,  there  may  be  a  decided 
difference  between  the  pulses,  the  left  being  almost  or  quite  imper- 
ceptible.^ The  face  is  generally  pale.  Difficulty  in  breathing,  con- 
trary to  what  might  be  expected,  is  not  a  prominent  symptom,  and 
is,  in  fact,  often  wanting,  while  sometimes  there  is  asthmatic  wheezing, 
or  the  breathing  is  irregular  and  of  the  Cheyne-Stokes  variety.  Gid- 
diness, spasmodic  seizures,  temporary  coma,  perverted  sensibility, 
occasionally  attend  or  follow  the  cardiac  attack,  and  so  does  peri- 
carditis.^ 

The  duration  of  the  fits  is  as  uncertain  as  are  the  causes  which 
excite  them.  They  may  cease  in  a  few  minutes  ;  they  may  last  an 
hour.  They  come  on  rapidly,  without  any  assignable  reason,  though 
they  are  generally  produced  by  exertion,  by  fatigue,  by  exposure  to 
cold,  or  by  mental  emotion.  However  provoked,  they  are  always 
dangerous.  The  heart  may  stop  beating  during  the  paroxysm.  "  My 
life  is  in  the  hands  of  any  rascal  who  chooses  to  annoy  and  tease 
me,"  was  a  saying  of  John  Hunter's.  And  in  truth,  after  he  had 
suffered  for  years  from  these  seizures,  his  irascible  temper  brought 
on  one  in  which  he  expired.  It  happens  sometimes  that  the  second 
attack  follows  at  a  short  interval  the  one  by  which  the  disease  first 
declares  itself,  and  proves  fatal.  Latham  ^  narrates  the  history  of  two 
cases  of  this  kind.  In  one,  life  ceased  in  a  fortnight  after  the  first 
seizure ;  in  the  other,  in  ten  days.  Nay,  it  may  be  cut  short  even  in 
the  midst  of  the  first  manifestation  of  the  malady.  Such  was  the 
death  of  Arnold  of  Rugby .^  On  the  other  hand,  I  have  had  a 
patient  under  my  care  who  for  weeks  at  a  time  has  five  or  six  attacks 
daily,  kept  in  check,  but  not  wholly  averted,  by  nitrite  of  amyl ;  and 
in  another  patient  as  many  as  forty  occurred  in  one  day. 

The  immediate  conditions  on  which  the  symptoms  of  the  attack 
depend  are  veiled  in  obscurity.     Whether  they  be  or  be  not  produced 

^  Hamilton  Osgood,  Amer.  Journ.  Med.  Sci.,  Oct.  1876. 

^  Clin.  Soc.  Transact.,  vol.  xvii.  p.  82. 

■*  Lectures  on  Diseases  of  the  Heart,  vol.  ii. 

*  Stanley,  Life  and  Correspondence,  of  Thomas  Arnold. 


DISEASES  OF  THE  HEART.  385 

by  temporary  increase  of  weakness  in  an  already  enfeebled  organ ; 
whether  a  cardiac  spasm  occur  or  do  not  occur ;  whether  the  pain 
and  the  sensation  of  approaching  death  be  or  be  not  caused  by  an 
acute  distention  of  the  heart  with  blood, — we  do  not  know.  All  we 
do  know  positively  is  that  the  excessive  pain  abruptly  appearing 
and  disappearing  points  to  deranged  innervation.  Yet  we  can  go  a 
step  farther ;  we  can  say  with  certainty  that  angina  pectoris  is  not 
often  an  uncomplicated  neuralgia.  Modern  research  has  taught  us 
that  these  outbreaks  of  a  cardiac  neurosis  are  frequently  linked  to 
some  structural  change.  This  structural  change,  so  far  as  we  can  now 
see,  is,  however,  not  at  all  times  the  same.  The  list  of  disorders  of 
the  heart  and  arteries  which  angina  pectoris  may  accompany  is, 
indeed,  very  long.  There  is  hardly  an  affection  of  the  walls  or  cavities 
of  the  heart,  scarcely  a  morbid  condition  of  the  arteries  that  nourish 
it  or  spring  from  it,  with  which  the  distressing  malady  has  not  been 
observed  to  be  associated.  It  has  been  found  as  an  attendant  on 
changes  in  the  coronary  artery ;  on  every  form  of  valvular  disease  ; 
on  thinning  of  the  parietes  of  the  heart ;  on  adherent  pericardium  ; 
on  fungoid  growths,  springing  from  the  apex  of  the  organ.^  It  has 
been  thought  that  combined  with  all  of  these  states  is  fatty  degenera- 
tion, which  thus  would  be  at  the  root  of  the  angina.^  Whether  this 
view  be  correct  or  not,  it  is  certain  that  fatty  degeneration  is  very 
often  conjoined  with  angina.  But  fatty  degeneration  occurs  also 
without  angina,  as  does  disease  of  the  coronary  arteries,  and  we  are 
thus  forced  to  admit  that,  however  frequent  the  association,  some  un- 
known element  is  still  the  determining  cause.  Yet  arteriosclerosis, 
general  or  localized,  in  the  heart  or  aorta,  with  changes  in  the  myo- 
cardium, is  the  most  common  obvious  lesion.  In  influenza  and  in 
diabetes  angina  is  also  met  with.  During  the  attack,  as  Brunton  has 
shown,  there  is  a  vasomotor  spasm  of  the  smaller  vessels,  with  a  rise 
in  blood-pressure  and  increased  tension  in  the  arteries. 

Angina  pectoris  is  now  very  generally  ranked  among  the  vaso- 
motor neuroses.  But  evidence  is  not  wanting,  as  Peter's  cases  prove,^ 
that  neuritis  of  the  cardiac  plexus,  the  neuritis  itself  being  consecutive 
to  aortitis,  is  the  cause  of  a  certain  number  of  cases. 

Angina  pectoris  is  easy  of  recognition.  The  points  to  ascertain 
are,  whether  it  is  linked  to  an  organic  cause,  and  to  what  organic 
cause,  or  whether  it  is  a  pure  neurosis,  either  primary  or  reflected.     It 


^  B.  Travers,  Medico-Chirurgical  Transactions,  vol.  xvii. 
^  Quain,  Medico-Chirurgical  Transactions,  vol.  xxxiii. 
^  La  Semaine  Medicale,  March,  1892. 


386  MEDICAL  DIAGNOSIS. 

may  be  a  question  whether  those  severe  pains  in  the  region  of  the  heart, 
which  occur  in  feeble  anaemic  persons  after  unaccustomed  exertion,  or 
which  are  brought  on  by  the  excessive  use  of  tobacco  or  of  tea,  or 
which  happen  in  rheumatic  or  gouty  subjects,  especially  while  suffer- 
ing from  indigestion,  are  real  angina,  or  whether  they  may  be  sepa- 
rated from  this  affection.  They  differ  from  it,  irrespective  of  being 
far  less  violent  and  less  radiating,  by  the  circumstances  leading  to  an 
attack,  and  by  their  constant  association  with  palpitation.  Intercostal 
neuralgia  with  palpitation  might  be  mistaken  for  angina ;  but  the  pain- 
ful spots  in  the  course  of  the  affected  nerve,  and  the  comparatively 
slight  suffering,  distinguish  it.  In  truth,  it  is  a  complaint  seated  only 
in  the  thoracic  walls,  and  referred  by  the  patient  to  the  heart.  Great 
irritability  of  the  heart,  attended  with  faintness,  with  sensations  of 
sinking,  with  flushing  alternating  with  pallor,  and  with  pain,  due  most 
likely  to  a  neurosis  of  the  cardiac  plexus,  is  discriminated  from  true 
angina  by  the  palpitations,  by  their  connection  with  pain  which  never 
rises  to  the  anguish  of  angina  pectoris,  by  the  periodical  nature  of  the 
pain,  its  nocturnal  occurrence,  and  its  duration  for  one  or  two  hours. 
Often,  too,  this  apparent  or  false  angina  is  found  in  persons  who  are 
hysterical,  or  are  subject  to  neuralgia,  or  are  laboring  under  a  disorder 
of  one  of  the  abdominal  viscera,  and  is  then  clearly  reflex.  It  must 
be,  however,  admitted  that  the  distinction  between  true  and  false 
angina  is  one  of  degree  rather  than  of  kind. 

Another  complaint  that  may  be  confounded  with  angina  is  what 
may  be  called  cardiac  epilepsy.  In  this  rare  affection  intense  pain  in 
the  region  of  the  heart  happens  in  paroxysms.  But  unconsciousness, 
however  temporary,  occurs  also,  and  the  pain  is  apt  to  foDow  rather 
than  to  precede  the  unconsciousness.  Yet  it  may  outlast  it,  and  be- 
come associated  with  twitching  of  the  muscles  of  the  face  and  with 
other  spasmodic  movements.  These,  the  unconsciousness,  and  the 
time  at  which  the  pain  happens,  distinguish  the  malady  from  those 
instances  of  angina  in  which,  owing  to  the  severity  of  the  pain,  the 
patient  passes  into  a  protracted  faint. 

Palpitation. — This  arises  in  various  affections  of  the  heart,  or- 
ganic as  well  as  functional.  It  bears  no  positive  relation  to  any 
special  cardiac  malady.  So,  too,  with  irregular  rhythm  of  the  heart's 
action,  with  which  palpitation  is  often  combined,  and  which,  when 
linked  to  a  disease  of  the  organ,  generally  means  failing  heart-muscle. 
But  palpitation,  with  or  without  irregular  rhythm,  may  take  place  in 
a  sound  heart,  disturbed  temporarily  by  the  condition  of  the  nervous 
system,  or  of  the  digestive. organs,  or  by  toxic  influences. 

Often  the  pulsations  of  the  heart  become  stronger,  more  extensive, 


DISEASES  OF  THE  HEART.  387 

and  more  perceptible,  from  mere  nervous  excitement.  But  it  is  not 
necessary  to  detail  the  symptoms  of  a  purely  nervous  palpitation. 
Every  one  has  experienced  them.  Every  one  knows  that  there  is  a 
feeling-  of  slight  constriction  about  the  chest,  with  a  hurried  breathing, 
and  a  strange  sensation  as  if  the  heart  were  leaping  from  its  place. 
Every  one  is  also  aware  that  the  organ  is  felt  thumping  against  the 
walls  of  the  chest,  and  with  a  force  which  shakes  them.  The  popular 
notion,  that  the  heart  is  the  seat  of  the  emotions,  is  based  on  these 
striking  evidences  of  its  disturbed  action. 

During  an  attack  of  palpitation  the  cardiac  sounds  are  clear  and 
ringing ;  in  neurasthenics  and  ansemics,  or  if  the  cardiac  excitement 
be  prolonged  and  violent,  a  systolic  murmur  at  the  apex  or  left  base  is 
not  uncommon. 

Persistent  rapidity  of  cardiac  action,  or  tachycardia.,  may  happen 
without  obvious  cause  in  persons  apparently  healthy.  It  is  very  com- 
mon in  irritable  hearts  and  in  exophthalmic  goitre.  Spender^  has 
called  attention  to  its  occurrence  among  the  earlier  signs  of  rheuma- 
toid arthritis.  The  extreme  frequency  of  the  action  of  the  heart  is 
in  some  instances  remarkable.  I  have  known  it  to  beat  over  two 
hundred  times  in  the  minute.  The  disorder  may  occur  in  paroxysms, 
described  as  "  cardiac  nerve  storms"  by  H.  C.  Wood.^  Great  rapidity 
may  be  joined  to  a  condition  in  which  the  two  sounds  are  precisely 
alike,  and  the  pauses  of  equal  length.  This  foetal  rhythm,  or  emhryo- 
cardia^  is  a  sign  of  heart  debility,  and  is  most  frequently  seen  in  con- 
nection with  marked  dilatation,  or  in  fevers.  In  gallop  rhythm  the 
cardiac  sounds  are  split,  most  often  the  second.  It  is  generally  found 
associated  with  the  weakening  heart  of  arteriosclerosis  and  of  inter- 
stitial nephritis. 

On  the  other  hand,  the  heart-beat  may  be  very  slow,  less  than 
thirty  times  in  the  minute.  We  may  fmd  this  slow  action,  brady- 
cardia., both  in  functional  and  in  organic  maladies,  though  it  is  most 
likely  that  the  nerve-centres  are  in  both  affected  in  the  same  way.^ 
Bradycardia  is  often  associated  with  atheroma  of  the  aorta  or  of  the 
coronary  arteries.  It  is  also  met  with  in  a  number  of  instances  of 
fatty  heart  and  in  old-standing  valvular  disease.  Its  association  with 
jaundice,  with  ursemia,  with  lead  poisoning,  with  feeble  heart  action 
during  convalescence  from  fevers,  Avith  apoplexy,  with  epilepsy,  with 

1  On  Osteo-Arthritis,  London,  1889. 
^  University  Medical  Magazine,  March,  1891. 

^  See  an  interesting  analysis  of  ninety-one  cases,  by  Prentiss,  Transact.  Assoc. 
Amer.  Phys.,  vol.  iv.,  1889. 


388  MEDICAL  DIAGNOSIS. 

affections  of  the  medulla  and  the  cervical  cord,  and  \vith  melancholia, 
is  well  known. 

FUNCTIONAL   DISORDERS   OF   THE    HEART. 

It  has"  just  been  stated  that  the  direct  symptoms  of  a  cardiac  dis- 
order— pain,  palpitation,  irregular  action — are  met  with  when  no 
recognizable  structural  change  has  taken  place.  Under  such  circum- 
stances the  affection  of  the  heart  is  termed  functional,  and  its  symp- 
toms are  those  mentioned,  variously  combined,  sometimes  the  one 
predominating,  sometimes  the  other.  These  functional  disorders  are 
very  much  more  frequent  than  the  organic.  They  are,  for  the  most 
part,  produced  by  direct  excitement  of  the  heart,  or  by  its  being  sym- 
pathetically disturbed  by  a  source  of  irritation  away  from  it,  or  in  the 
system  at  large.     The  symptoms  may  be  said  to  constitute  the  disease. 

Functional    Disorders   characterized  by   Palpitation,    asso- 
ciated or  not  with  Change  of  Rhythm. 

We  have  already  briefly  mentioned  the  causes  of  augmented  action 
which  are  associated  with  organic  changes,  and  those  which  occasion 
temporary  disturbance  of  the  heart.  A  more  lasting  form  of  palpita- 
tion is  engendered  when  the  organ  is  kept  constantly  excited  by  a 
deranged  condition  of  some  viscus  remote  from  it ;  by  the  use  of 
stimulating  substances ;  or  by  some  general  morbid  state.  Thus,  a 
disordered  stomach  or  liver  leads  to  a  reflex  disturbance  of  the  heart, 
which  ceases  if  the  disorder  of  the  stomach  or  liver  be  remedied.  In 
gouty,  lithsemic,  and  rheumatic  persons  the  heart  frequently  pulsates 
with  increased  quickness,  and  sometimes  with  marked  irregularity. 
Special  articles  of  diet,  especially  tea  or  coffee,  produce  palpitation ; 
so  does  the  inordinate  use  of  tobacco  and  of  alcohol.  Overwork, 
worry,  immoderate  dancing,  masturbation,  and  excessive  sexual  indul- 
gence, but  particularly  masturbation,  are  prolific  sources  of  continued 
palpitation.  Women  who  are  hysterical,  or  whose  uterine  functions 
are  disordered,  suffer  from  palpitation.  So  do  anaemic  persons  and 
neurasthenics  complain  of  the  beating  of  the  heart. 

A  troublesome  kind  of  palpitation  is  that  attended  with  marked 
irregularity  of  the  action  of  the  heart,  displaying  itself  by  the  beat 
being  now  slow,  now  fast,  or  occasionally  intermitting.  Sufferers 
from  lithsemia  or  gout,  or  old  persons  with  feeble  digestion,  are  par- 
ticularly liable  to  it.  This  form  of  palpitation  is  not  without  danger. 
It  is  prone  to  be  associated  with  an  alteration  in  the  structure  of  the 
heart,  such  as  flabbiness  of  the  walls. 


DISEASES  OF  THE  HEART.  389 

Some  who  experience  fits  of  palpitation  faint  away  during  these. 
But  the  ahnost  complete  suspension  of  the  movements  of  the  heart 
which  characterizes  an  attack  of  syncope  has  no  definite  connection 
with  any  form  of  palpitation,  nor,  indeed,  with  any  form  of  cardiac 
disorder,  organic  or  functional.  In  those  who  are  subject  to  attacks 
of  palpitation  or  to  irregular  action  of  the  heart,  the  organ  may  finally 
become  enlarged. 

A  peculiar  irregular  action  of  the  heart  has  been  much  discussed 
under  the  name  of  hemisy stole.  Leyden  describes  cases  in  which 
with  every  two  beats  of  the  heart  only  one  beat  of  the  pulse  is  felt, 
and  attributes  this  to  the  right  ventricle  contracting  alternately  with 
the  left.  Different  explanations  have  been  given  of  the  fact,  but  the 
observations  of  Riegel  and  Lachmann,  while  they  do  not  strictly 
confirm  the  alternate  action  of  the  ventricles  as  the  cause  of  the 
phenomenon,  point  to  irregular  contraction  of  the  muscles  of  the 
heart  as  the  cause.^ 

We  sometimes  meet  with  a  singular  form  of  functional  disturb- 
ance of  the  heart  which  leads  to  textural  changes,  and  to  which 
Graves  called  particular  attention.  It  consists  in  a  long-continued 
excitement  of  the  organ,  as  evidenced  by  its  increased  force  and 
rapid  and  irregular  action,  which  is  followed  by  a  swelling  of  the 
thyroid  gland,  pulsation  of  the  arteries  of  the  neck,  and  prominence 
of  the  eyeballs.  This  disease,  exophthalmic  goitre^  is  most  commonly 
observed  in  women,  and  connected  with  hysteria,  neuralgia,  or 
uterine  disturbance  ;  it  has  in  some  instances  an  evident  origin  in 
worry  or  in  shock.  It  is  generally  considered  to  be  owing  to  an 
affection  of  'the  cervical  sympathetic  nerve.  But  its  cause  is  far  from 
certain.  There  are  those  who  hold  it. to  be  a  neurosis  of  the  nerve- 
centres,  especially  of  fhe  vagus  centre  ;  and  the  detection  of  ptomaines 
in  the  urine  is  thought  to  be  a  proof  that  this  apparent  neuro-cardial 
malady  is  really  consequent  upon  secondary  disturbance  of  the 
nervous  system  due  to  poisonous  products  from  the  thyroid. 

The  most  characteristic  sign,  the  greatly  accelerated  heart's  action, 
varies  much  in  extent.  All  the  signs  may  remit  or  may  become 
aggravated  from  time  to  time,  and  especially  during  a  severe  attack 
of  palpitation.  The  turgescence  of  the  thyroid  gland  arises  quite  in- 
dependently of  the  usual  exciting  causes  of  bronchocele.  It  is  ac- 
companied by  a  pulsating  thrill  similar  to  that  of  an  aneurismal 
varix,  and  by  a  distinct  throb.  At  an  advanced  period  of  the  com- 
plaint, these  signs  subside,  and  the  gland  becomes  more  solid.     In- 

^  Virchow's  Archiv,  Bd.  xliv.  ;    Deutsches  Arch.  f.  kliii.  Med.,  Bd.  xxvii.  p.  393. 


390  MEDICAL   DIAGNOSIS. 

deed,  the  whole  affection  may  disappear,  and  the  gland,  the  eyes,  the 
beat  of  the  carotids,  the  action  of  the  heart,  all  return  to  a  normal 
condition.  On  the  other  hand,  hypertrophy  and  dilatation  may  re- 
sult from  the  cardiac  palpitations,  or  the  malady  be  noticed  in  asso- 
ciation with  valvular  disease,  under  circumstances  which  make  it  a 
question  whether  this  has  followed  it  or  is  a  mere  concomitant. 

The  protrusion  of  the  eyeball  is  often  combined  with  a  symptom 
that  Graefe  particularly  observed, — a  want  of  agreement  between  the 
movement  of  the  lid  and  the  raising  or  depressing  of  the  glance. 
The  palpebral  aperture  is  wide,  owing  chiefly  to  spasm  of  the  upper 
lid,  and  this  spasm  of  the  elevator  of  the  upper  eyelid  is  held  to  be 
pathognomonic.^  Another  symptom  of  importance  is  trembling  of 
the  hands.  The  tremor  is  fine,  and,  as  Charcot  pointed  out,  affects 
the  whole  hand,  but  not  individual  fingers.  There  is  also,  as  Charcot 
shows,  greatly  lessened  resistance  to  the  galvanic  current ;  but  this 
sign  is  not  of  much  value,  as  Cardew  ^  has  found  the  electric  resist- 
ance to  diminish  greatly  whenever  the  skin  is  moist.  Other  symp- 
toms are  cramps,  usually  at  night,  epistaxis,  oedema  of  the  legs  and 
eyelids,  lessened  respiratory  expansion,  moderate  elevation  of  tem- 
perature, sensation  of  heat,  flushed  and  moist  skin,  paroxysmal 
attacks  of  diarrhoea,  atony  of  the  large  intestine,  intermittent  swell- 
ing and  pain  in  the  jomts,  pigmentation,  urticaria,  pruritus,  bulimia 
without  gain  in  flesh,  emaciation,  glycosuria,  migraine,  rheumatic 
symptoms,  and  mental  derangement.  All  the  physical  manifesta- 
tions of  the  disease  are  double-sided  ;  and  this,  with  the  unchanged 
state  of  the  pupils,  serves  to  distinguish  it  from  those  rare  cases  ^ 
where  a  thyroid  growth  pressing  on  the  sympathetic  on  one  side 
produces  symptoms  of  exophthalmic  goitre,  including  the  palpita- 
tions. 

In  the  distinction  from  ordinary  goitre,  the  absence  of  eye  and 
heart  symptoms  is  of  most  value.  There  is  also  no  murmur  heard 
over  the  enlarged  thyroid  gland ;  whereas  in  Graves's  disease  a  con- 
tinuous murmur  there  is  most  common,  and  is,  indeed,  looked  upon 
by  Guttmann  as  of  the  greatest  diagnostic  importance,  especially  aiding 
us  in  those  doubtful  cases  in  which  the  exophthalmos  is  wanting.  My 
own  experience  confirms  this  statement. 

There  is  another  form  of  functional  disorder  of  the  heart  so  pecu- 
liar as  to  demand  a  special  notice.     It  is  the  curious  cardiac  malady 

^  Abadie,  La  France  Medicale,  vol.  ii.,  1881. 

2  Lancet,  Feb.  1891. 

^  Eulenberg,  Ziemssen's  Cyelopsdia. 


DISEASES  OF  THE  HEART.  391 

of  which  we  saw  so  many  examples  in  soldiers  during  our  civil  war, 
to  which  I  gave  the  name  of  "  writable  hearty''''  and  which  we  also  find 
occurring  in  private  life.  Its  main  symptoms  are  habitual  frequency 
of  the  action  of  the  heart,  constantly  recurring  attacks  of  palpitation, 
and  pain  referred  to  the  lower  portion  of  the  prsecordial  region.  The 
palpitations  come  on  chiefly  during  exercise,  but  may  also  take  place 
when  the  patient  is  quiet,  and  in  many  cases  happen  most  often  at 
night,  thus  interfering  with  sleep.  Those  who  are  subject  to  the  dis- 
order complain  much  of  headache  and  of  dizziness,  and  especially  of 
being  thus  affected  when  suffering  from  palpitation.  The  pain  is 
generally  dull  and  constant,  but  is  often  also  described  as  shooting, 
and  as  taking  place  only  in  paroxysms.  Its  chief  seat  is  near  the  apex, 
and  it  is  combined  commonly  with  excessive  cutaneous  sensibility. 
Often  there  is  pain  nowhere  else  in  the  body ;  but  in  some  instances 
the  cardiac  distress  is  associated  with  pain  in  the  back,  which  itself  is 
not  unusually  connected  "with  the  excretion  of  oxalate  of  lime  by  the 
kidneys. 

The  action  of  the  heart  is  very  rapid,  and  in  many  instances  its 
rhythm  is  irregular.  The  impulse  is  slightly  extended,  but  not  forci- 
ble, like  that  of  hypertrophy :  it  is  rather  abrupt  and  jerky.  As  a 
rule,  to  which  I  have  met  with  but  few  exceptions,  the  sounds  of 
the  heart  are  modified  as  follows :  the  first  sound  is  short,  some- 
times sharp,  resembling  the  second  sound ;  at  other  times  it  is 
extremely  deficient  and  hardly  recognizable ;  the  distinctness  of  the 
second  sound  is  much  heightened.  We  either  hear  no  murmurs  in 
the  heart  or  in  the  neck,  or  they  are  inconstant.  The  area  of  per- 
cussion dulness  does  not  appear  to  be  augmented.  The  pulse  is 
almost  always  easily  compressible ;  it  may  or  may  not  share  the 
character  of  the  impulse.  It  is  usually  very  much  influenced  by 
position,  falling  rapidly  twenty  beats  or  more  when  the  erect  posture 
is  exchanged  for  the  recumbent.  The  increased  frequency  of  beat 
is  not  connected  with  increased  frequency  of  respiration,  for  often 
with  a  pulse  of  one  hundred  the  respirations  scarcely  exceed  twenty 
in  the  minute.  The  disorder  is  very  obstinate,  and  improvement 
comes  but  slowly. 

The  cause  of  the  morbid  cardiac  impressibility  is  difficult  to  ascer- 
tain. It  seems  in  many  instances  to  have  followed  fatiguing  marches  ; 
in  some,  to  have  occurred  after  fevers  or  diarrhoea ;  it  was  not  con- 
nected with  scurvy,  or  with  the  abuse  of  tobacco.  That  it  was  not 
due  to  ansemia  was  proved  by  the  general  aspect  of  the  men,  which 
was  often  that  of  ruddy  health.  Similar  conditions  of  the  heart  occur 
from  excessive  dancing,  excessive  smoking,  and  certain  occupations, 


392  MEDICAL  DIAGNOSIS. 

such  as  glass-blowing.     For  a  fuller  consideration  of  the  subject  I 
refer  to  observations  elsewhere  detailed.^ 

Yet  another  form  of  functional  cardiac  disorder  is  the  one  which 
I  have  described  under  the  name  of  cardiac  asthenia,  or  heart  exhaus- 
tion. It  shows  essentially  the  signs  of  a  weak  heart,  and  follows 
long-continued  worry  and  overwork.  There  is  rapidity  of  cardiac 
movement  with  very  feeble  action,  and  a  great  tendency  to  faintness. 
The  breathing  is  singularly  undisturbed.  The  impulse  of  the  heart  is 
weak,  the  first  sound  short,  valvular,  the  capillary  circulation  defective. 
The  duration  of  the  cases  is  a  long  one,  and  recovery  takes  place  but 
gradually.  In  the  cases  that  are  not  purely  nervous,  but  in  which  the 
heart-muscle  is  enfeebled,  shortness  of  breath  and  functional  dynamic 
apex  murmurs  are  ofteij  noticed.^ 

These,  then,  are  the  principal  varieties  of  functional  disorder  of  the 
heart.  It  is  hardly  necessary  again  to  state  that  the  physical  signs 
present  the  most  certain,  if  not  the  only,  means  of  distinguishing  the 
functional  from  the  structural  affection.  They  show  us  that  neither 
the  size  of  the  organ  nor  its  sounds,  with  the  exceptions  above  men- 
tioned, are  materially  different  from  what  they  are  in  health. 

The  irritable  heart  just  described,  as  indeed  other  forms  of  func- 
tional heart  disorder,  may  pass  into  organic  cardiac  disease  by  the 
constant  overaction  of  the  heart.  And  overaction  or  strain  may  also, 
as  I  have  proved  in  the  publications  just  referred  to,  lead  to  valvular 
affection,  sometimes  by  preceding  hypertrophy,  at  other  times  by  a 
slow  process  of  inflammation  or  disorganization  engendered  at  or 
near  the  seat  of  the  valve.  Of  this  I  published  several  instances  in 
the  "Memoirs  of  the  Sanitary  Commission."  Others  have  been 
brought  forward  by  Allbutt^  that  happened  among  persons  engaged 
in  vocations  requiring  sustained  and  oft-repeated  muscular  effort, — 
such  as  hfters,  smiths,  sawyers.  And  in  his  elaborate  monograph, 
Seitz*  has  detailed  several  fatal  cases  in  which  the  symptoms  of  a 
fatigued  heart,  due  to  strain,  were  followed  by  extensive  dilatation 
without  valvular  disease.  Leyden,  too,  has  added  to  our  accurate 
knowledge  of  the  subject.'^ 

^  Medical  Memoirs  of  the  U.  S.  Sanitary  Commission,  1867  ;  American  Journal 
of  the  Medical  Sciences,  January,  1871  ;  and  the  Third  Toner  Lecture,  Smithsonian 
Institution,  1874,  "On  Strain  and  Overaction  of  the  Heart,"  where  also  the  forms 
of  irritable  heart  occurring  in  civil  life  are  described. 

^  Amer.  Journ.  Med.  Sci.,  April,  1894. 

^  St.  George's  Hospital  Reports,  1872. 

*  Die  Ueberanstrengung  des  Herzens,  1875. 

^  Die  Herzkrankheiten  in  Folge  von  Ueberanstrengung,  Berlin,  1886. 


DISEASES  OF  THE  HEART. 


393 


ORGANIC   DISEASES  OF   THE  HEART. 
Organic  diseases  of  the  heart  may  be  classified  as  follows 

Organic  Diseases  of  the  Heart. 


Diseases  affecting  the  walls  of  the  heart,  and 
mostly  changing  the  size  of  the  cavities. 


Diseases  affecting  chiefly  the  walls  alone 


of  membranes. 


Inflammations 


■  ■  ■  ■  i    of  muscular 
[       structure. 
Diseases  of  the  valvular  apparatus 


Diseases  affecting  the  pericardium 


Congenital    diseases 


Hypertrophy. 

Dilatation. 

Atrophy. 

Fatty  degeneration. 

Parenchymatous  degeneration. 

Fibroid  heart,  cardio-sclerosis,  etc. 

Malformations. 

Rupture  of  the  heart. 

Injuries  and  wounds. 

Aneurism  of  the  heart. 

New  growths  and  parasites. 

Endocarditis. 

Pericarditis. 

Myocarditis  (Carditis). 

Valvular  diseases. 

Chronic  pericarditis. 

Hydropericardium. 

Heemopericardium. 

Pneumo-hydropericardium. 

New    formations    on    pericardium : 

cancer,  tubercle,  etc. 
Abnormal  positions. 
Closure  of  openings  of  right  heart. 
Opening  between  the  ventricles. 
Narrowing  and  closure  of  pulmonary 

artery,  etc. 


These  are  the  organic  diseases  of  the  heart,  save  the  rarest.  But 
let  us  study  the  cardiac  maladies  according  to  their  symptoms  and 
signs  rather  than  according  to  their  anatomical  classification. 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Region ;  the 
Symptoms  of  a  Disturbed  Circulation ;  and  a  Change  in 
the  Sounds  of  the  Heart,  or  their  Replacement  by 
Murmurs. 

AU  the  acute  affections  of  the  heart  come  under  this  head.  In 
all,  the  sounds  are  either  changed  in  their  character  or  are  replaced 
by  murmurs.  This  is  certainly  true  of  endocarditis  and  pericarditis. 
All  the  acute  disorders  give  rise,  further,  to  more  or  less  pain,  and  to 
anxiety  of  expression ;    in  all  there  is  fever ;    all  are  prone  to  occur  in 


394  MEDICAL  DIAGNOSIS. 

connection  with  other  morbid  conditions,  and  especiahy  with  a  con- 
taminated state  of  the  blood.  In  ah,  moreover,  the  symptoms  of  a 
disturbed  circulation  are  met  with :  palpitation,  irregular  action  of  the 
heart,  deranged  flow  of  blood  through  the  capillaries  of  different 
organs,  and  a  tendency  to  dropsical  accumulations.  That  these 
symptoms  are  not  so  clearly  defined  as  in  some  of  the  chronic  cardiac 
maladies  is  owing  to  the  shorter  time  the  complaint  lasts. 

Acute  Endocarditis. — Acute  inflammation  of  the  lining  mem- 
brane of  the  heart  is  very  rarely  a  primary  disease.  It  sometimes 
results  from  violent  efforts,  or  from  blows  or  other  injuries  to  the 
chest.  It  is  often  connected  with  an  acute  infective  process  or  a  viti- 
ated condition  of  the  blood,  as  in'  pneumonia,  in  chorea,  in  cancer, 
in  scarlet  fever,  in  pyaemia,  in  puerperal  fever,  in  Bright's  disease,  or 
in  diabetes.  But  its  most  frequent  association  is  with  articular 
rheumatism. 

The  chief  source  of  danger  in  endocarditis  is  the  tendency  the  in- 
flammation has  to  limit  itself.  It  is  confined  to,  or  is  most  strikingly 
developed  at,  a  part  which  bears  least  of  ah  any  impairment, — at  the 
valves, — and  often  leaves  behind  it  some  permanent  disorganization 
of  their  delicate  structure.  But  it  does  not  generally  affect  the  entire 
valvular  apparatus :  that  of  the  left  side  is  usually  alone  the  seat  of 
disease.  What  morbid  anatomy  thus  teaches,  explains  the  occurrence 
and  situation  of  the  principal  sign  by  which  endocarditis  is  recognized. 
The  roughness  of  the  surface  over  which  the  blood  flows,  the  minute 
vegetations,  interfering  with  the  function  of  the  valves,  occasions  a 
distinct  murmur,  which  is  mostly  confined  to  the  mitral  and  aortic 
openings  ;  it  may  be  preceded  by  an  altered  character  of  the  first 
sound  or  its  reduplication. 

Besides  this  blowing  sound,  there  are  other  signs  worthy  of  note. 
It  is  true,  they  do  not  form  so  leading  a  feature  of  the  disease  ;  still, 
they  aid  in  its  correct  appreciation.  The  excited  heart  beats  with 
augmented  force,  and  sometimes  with  great  irregularity,  as  the  not 
unusual  doubling  of  the  second  sound  at  the  base  proves.  The  size 
of  the  organ  is  not  notably  increased,  except  in  those  cases  in  which 
its  cavities  are  choked  with  blood  or  fibrin-clots.  The  pulse  corre- 
sponds to  the  action  of  the  heart ;  yet  not  so  closely  as  might  be  ex- 
pected. It  is,  for  the  most  part,  frequent  and  strong.  It  becomes 
irregular,  one  beat  being  strong,  the  next  weak,  if  the  circulation 
through  the  heart  be  seriously  obstructed ;  it  may  be  feeble  while  the 
heart  is  thumping  with  violence  against  the  walls  of  the  chest. 

The  general  symptoms  are  not  uniform.  There  is  usually  a  sense 
of  uneasiness  around  the  heart,  with  a  fever  showing  a  temperature 


DISEASES  OF  THE  HEART.  395 

ranging  from  101°  to  103°,  a  short  cough,  palpitation  and  some  irregu- 
larity of  cardiac  action,  difficulty  of  breathing,  and  anxiety  depicted 
on  the  countenance.  To  these  are  not  uncommonly  added  turges- 
cence  of  the  face,  headache,  slight  delirium,  gastric  irritability,  diar- 
rhoea, and  rigors,  followed  by  sensations  of  heat.  Pain  in  the  heart 
is  rare,  and  is  not  likely  to  happen  unless  the  pericardium  or  the 
muscular  walls  be  implicated.  In  some  cases  an  eruption  of  subcu- 
taneous fibrous  nodules  occurs,  especially  in  the  rheumatic  endo- 
carditis of  children. 

Now,  where  these  symptoms  are  present ;  where  they  manifest 
themselves  in  one  whose  system  is  in  a  state  in  which  endocarditis  is 
apt  to  take  place  ;  and  where  they  are  accompanied  by  a  blowing 
sound  recently  and  rather  suddenly  developed, — we  are  certain  that 
inflammation  is  working  its  changes  in  the  hning  membrane  of  the 
heart.  Yet  some  circumspection  is  requisite  before  arriving  at  this 
conclusion.  A  murmur  may  be  attended  with  febrile  signs  and  not 
be  dependent  upon  acute  endocarditis.  The  sound  may  be  of  organic 
origin  and  chronic ;  or  it  may  be  engendered  in  the  course  of  an  idio- 
pathic fever,  and  the  lining  membrane  of  the  heart  be  unaltered. 

In  the  first  instance  the  murmur  is  old,  and  results  from  some 
chronic  injury  to  the  valve,  the  attending  fever  being  an  accidental 
complication.  Here  is  undoubtedly  a  difficult  case  for  diagnosis.  We 
see  the  patient  for  the  first  time  ;  he  has  fever ;  his  heart  is  acting 
strongly  :  a  distinct  blowing  sound  is  perceived  over  it.  How  are  we 
to  tell  that  his  complaint  is  not  acute  endocarditis  ?  We  have  no 
absolute  means  of  deciding  that  it  is  not.  Yet  by  careful  inquiry  we 
can  usually  come  to  a  knowledge  of  the  truth.  If  the  patient  do  not 
recollect  to  have  suffered  previously  from  dyspnoea  or  palpitation ;  if 
the  cardiac  excitement  be  well  defined  ;  if  the  face  denote  distress  ;  if 
the  accompanying  symptoms  indicate  a  state  that  is  prone  to  be  com- 
plicated with  endocardial  inflammation, — it  is  this  disease  under  which 
he  is  laboring.  Then  the  murmur  is  not  so  rough,  is  not  often  heard 
except  during  the  systole,  and  may  be  changeable  in  its  seat,  which 
an  old-standing  murmur  never  is.  Besides,  it  is  not  associated  with 
those  signs  of  enlargement  which  are  invariably  found  when  the  valves 
have  been  for  any  length  of  time  affected,  unless  the  acute  inflamma- 
tion occur  in  a  heart  the  valves  of  "which  have  been  previously  spoiled. 
Under  such  circumstances,  we  can  only  conjecture  what  is  going  on 
within  the  organ  from  its  increased  excitement,  and,  if  I  may  take  my 
own  experience  as  the  general  rule,  from  the  character  of  the  blowing 
sound  undergoing  alteration.  It  is  rendered  often  less  distinct,  nay,  it 
is  even  entirely  muffled,  by  the  products  of  the  recent  inflammation. 


396  MEDICAL   DIAGNOSIS. 

But  how  are  we  to  distinguish  between  the  soft  murmur  arising  in 
the  course  of  fevers,  and  tliat  resulting  from  effused  lymph  ?  It,  too,  is 
not  rough.  It,  too,  happens  with  the  impulse.  It,  too,  is  preceded 
by  a  lengthening  of  the  first  sound.  Here  is  assuredly  a  strong  re- 
semblance ;  yet  by  no  means  an  identity.  The  blowing  sound  in 
fevers  does  not  exist  until  the  blood  is  profoundly  altered.  In  endo- 
carditis it  takes  place  almost  as  soon  as  the  disease  begins.  The  heart 
in  fevers  is  not  so  directly  disturbed  in. its  action,  and  we  do  not  find 
symptoms,  local  as  well  as  general,  which  show  that  the  circulation  is 
obstructed.  The  blowing  sound  is  rarely  at  the  apex,  but  more  over 
the  body  of  the  heart.  To  this  some  weight  may  be  attached,  since 
the  murmur  of  endocarditis  is  very  apt  to  be  heard  at  the  apex.  But 
to  no  fact  ought  as  much  weight  to  be  attached  as  to  the  one  first 
mentioned,  that  the  murmur  takes  place  early  and  not  late  in  the 
disease. 

Throughout  this  description  of  endocarditis,  only  simple,  uncom- 
plicated cases  have  been  kept  in  view;  yet  it  is  not  often  that  the 
malady  is  seen  in  so  pure  a  type.  It  is  more  generally  accompanied 
by  the  friction  sounds  and  other  signs  of  acute  pericarditis,  and  by  the 
swollen  joints,  the  painful  movements,  the  acid  perspirations,  of  acute 
rheumatism  ;  or  by  the  characteristic  appearances  on  the  skin  of  ery- 
thema marginatum ;  or  by  tonsillitis  ;  or  by  the  kidney  symptoms  of 
Bright's  disease ;  or  by  the  evidences  of  chorea,  or  of  gonorrhoea, 
pysemia,  or  septicaemia. 

Nor  is  a  murmur  in  endocarditis  invariable.  When  the  seat  of 
the  inflammation  is  not  near  the  valves,  a  murmur  is  not  generated. 
There  may  be  also  none  if  no  vegetations  exist  on  the  valves,  and 
perhaps  in  states  of  the  exudation  with  which  we  are  at  present  un- 
acquainted. We  cannot,  under  such  circumstances,  detect  an  attack 
of  endocarditis.  Yet  it  may  be  even  then  strongly  suspected  to  be 
present  if  great  excitement  or  irregularity  of  the  heart  manifest  itself 
in  a  person  who  is  laboring  under  a  disease  which  predisposes  to  en- 
docardial inflammation,  such  as  rheumatism. 

Clots  of  fibrin  may  form  in  the  heart,  and  they  or  the  vegetations 
which  stud  the  valves  be  washed  into  the  circulation.  The  formation 
of  clots  in  the  cardiac  cavities,  if.  at  all  extensive,  announces  itself  by  a 
sudden  appearance  or  a  sudden  augmentation  of  the  symptoms  of  ob- 
structed circulation  and  of  marked  dyspnoea ;  the  pulse  is  frequent 
and  feeble,  the  action  of  the  heart  becomes  exceedingly  irregular,  its 
sounds  are  indistinct,  or  a  more  or  less  distinct  murmur  is  heard,  and 
the  extent  of  the  prsecordial  percussion  dulness  is  increased.  Great 
anxiety,  nausea  and  vomiting,  delirium,  turgid  veins  in  the  neck,  and 


DISEASES  OF  THE  HEART.  397 

fits  of  fainting,  are  also  among  the  manifestations  of  the  clogged  blood 
in  the  heart.  Yet  these  phenomena  are  not  absolutely  distinctive,  for 
excessive  dilatation  without  heart-clot  will  give  much  the  same  ;  and 
Walshe  records  that  the  effects  of  a  rupture  of  a  sigmoid  valve  or 
of  a  tendinous  cord,  during  the  acute  endocardial  disease,  will  give  rise 
to  symptoms  exactly  similar  to  the  obstruction  of  the  circulation  re- 
sulting from  polypoid  concretions  in  the  heart.  When  these  thrombi 
form  from  other  causes  than  endocarditis,  as  from  heart  palsy  or 
morbid  states  of  the  blood  unconnected  with  inflammation,  the  symp- 
toms are  not  different. 

Portions  of  the  clots,  or  of  the  vegetations  on  the  valves,  are 
sometimes  washed  into  the  current,  and  the  embolism  occasions 
symptoms  that,  before  we  were  aware  of  the  damage  to  which  the 
detached  masses  may  give  rise,  appeared  inexplicable.  But  now — 
when  we  see  the  circulation  speedily  diminished  or  arrested  in  a 
limb,  and  the  limb  becoming  painful,  swollen,  or  beginning  to  mor- 
tify ;  when  we  find  that  the  flow  of  the  blood  through  the  brain  has 
become  suddenly  disturbed,  and  the  muscles  of  one  side  drop  para- 
lyzed ;  when  the  difficult  breathing  becomes  rapidly  still  more  diffi- 
cult, while  there  are  no  signs  of  a  superadded  affection  of  the  lung, 
nay,  while  the  power  fully  to  expand  the  lungs  remains  unimpaired, 
or  while  an  effusion  of  fluid  into  the  air-vesicles  follows  the  dyspnoea 
— we  know  what  has  happened  :  we  know  that  a  broken-off  piece  of 
fibrin  has  been  driven  into  the  artery  of  the  limb,  or  into  the  brain, 
or  into  the  branches  of  the  pulmonary  artery,  and,  being  too  large  to 
go  any  farther,  has  stuck  fast,  and  has  given  rise  to  all  these  sudden 
and  sad  consequences.  Sad  indeed  they  are ;  for,  even  if  the  plugs 
do  not  lead  to  an  immediately  fatal  result,  they  lay  the  ground- 
work for  structural  alterations  in  any  tissue  in  which  they  become 
impacted. 

Inflammation  of  the  aorta  may  occasion  many  of  the  symptoms  of 
acute  endocarditis  ;  at  all  events,  it  may  do  so  when  the  upper  part  of 
the  aorta  is  implicated.  But  it  is  not  a  condition  that  can  be  dis- 
criminated with  certainty.  The  most  significant  signs  are  hurried 
respiration,  a  sharp,  rapid  pulse,  tumultuous  action  of  the  heart,  pain 
in  the  prsecordial  region,  often  greatly,  increased  by  movements,  and 
also  felt  along  the  course  of  the  spine,  burning  pain  referred  to  the 
sternum,  great  anxiety.  The  history  of  the  case  points  to  gout,  alco- 
holism, syphilis,  or  malaria.  There  may  be  paroxysms  of  pain  such 
as  occur  in  angina  and  a  loud  systolic  blowing  sound.  When  the 
abdominal  aorta  is  affected,  we  notice  strong  local  pulsation,  and  a 
marked  murmur  will  be  heard  with  greatest  distinctness  at  or  near 


398  MEDICAL  DIAGNOSIS. 

the  seat  of  the  inflammation.  In  some  cases  of  aortitis,  Bright^  ob- 
served an  extremely  high  degree  of  morbid  sensibility  over  all  parts 
of  the  body,  which  caused  the  patient  to  scream  ^^ith  pain  when  his 
wrists  were  merely  touched.  The  disorder  is  most  apt  to  happen 
in  cachectic  persons  ;  and  it  has  been  repeatedly  observed  in  those 
attacked  mth  er^'sipelas,  or  after  operations  and  injuries.^ 

Dissimilar  causes  may  lead  to  different  sites  of  endocardial  mflam-  * 
mation.     Thus,  puerperal  endocarditis  is  apt  to  localize  itself  in  the 
right  heart.     It  has  pulmonary  complications,  and  the  progress  of  the 
disease  is  often  slow ;  it  may  last  several  months.'^ 

There  is  a  form  of  endocarditis  which  may  be  here  briefly  men- 
tioned,— ulcerative  endocarditis.  It  is  not  common  m  this  country, 
although  I  have  seen  a  number  of  instances.  It  occurs  mostly  in 
connection  with  low  forms  of  rheumatism  or  with  blood-poisoning, 
and  the  symptoms  of  this,  or  of  pysemia,  or  a  low  septic  fever,  are 
apparently  the  prominent  features  of  the  case,  or  it  may  happen  as 
subsequent  to  pneumonia.^  The  ulceration  perforates  the  valves,  and 
may  extend  into  the  muscular  structure  of  the  heart ;  pneumonia  or 
pleurisy,  embolic  formations,  and  infarcts  and  metastatic  abscesses 
in  various  parts  of  the  body  are  among  the  common  attendants, — 
pneumonia  is  especially  frecjuent.  The  perilous  affection  shows  an 
endocarditis  developing  amidst  the  symptoms  of  profound  blood- 
poisoning  and  prostration,  although  these  physical  signs  may  be 
masked  by  a  pericardial  complication.  Marked  and  recurring  chills, 
like  those  of  malarial  fever,  but  coming  on  irregularly  ;  a  temperature 
of  105°  to  107°  ;  an  extremely  rapid  pulse,  becommg  suddenly  much 
slower,  though  very  irregular ;  profuse  sweats ;  vertigo ;  delirium 
followed  by  stupor ;  dry  tongue ;  vomiting  and  diarrhoea ;  jaundice  ; 
tenderness  over  liver  and  spleen :  and  scanty,  albuminous  urme, — 
are  among  the  prominent  features  of  the  malady.  As  regards  the 
thoracic  symptoms,  there  may  be  oppression,  dyspnoea,  and  pain,  yet 
these  symptoms  may  be  wholly  wanting.  In  some  instances  a  peculiar 
diffused  rose  rash,  here  and  there  mixed  with  papules  and  spots  of 
ecchymosis,  is  noticed ;  in  others  there  are  capillar^''  embolisms.  By 
some,  ulcerative  endocarditis  is  looked  upon  as  diphtheritic ;  mdeed, 
when  it  has  happened  during  puerperal  fever,  diphtheritic  exudations 
have  been  found  on  the  mucous  membrane  of  the  vagina  and  uterus. 
It  is  certain  that  the  pyogenic  cocci  are  constantly  present,  generally 

^  Guy's  Hospital  Reports,  vol.  i. 

^  Cheyers,  ibid.,  vol.  vi.,  and  2d  Series,  vol.  i.  ;  Osier,  Gulstonian  Lectures. 

^  Luzet  et  Ettlinger,  Archives  Generales  de  Medecine,  Jan.  1891. 

*  Archives  de  Physiologie.  Aug.  1886. 


DISEASES  OF  THE  HEART.  399 

streptococci,  staphylococcci,  and  pneumococci,  and  are  found  not  only 
in  the  heart,  but  also  in  the  infarcts  in  the  spleen  and  liver.  Death 
is  the  common  ending, — either  by  gradual  exhaustion,  or  suddenly 
by  the  tearing  away  of  the  injured  valves. 

The  disease  is  extremely  rare  in  children.  It  is  more  often  mis- 
taken for  typhoid  fever  than  for  any  other  disease.  But  it  is  also 
mistaken  for  typhoid  pneumonia,  for  cerebro-spinal  fever,  and  for 
hemorrhagic  smallpox.  When  ulcerative  endocarditis  happens  in 
connection  with  malarial  poisoning,  a  not  infrequent  association  in 
Africa,  its  seat  of  predilection  is  in  the  aortic  valves.^  The  most 
common  type  of  the  disease  is  the  typhoid  type.  The  malignant  endo- 
carditis may  become  engrafted  on  a  chronic  valve  lesion.  Its  clinical 
association  with  a  suppurative  wound  or  puerperal  disease  is  common, 
and  we  find  it  also  in  abscesses  in  the  throat,  and  in  combination  with 
suppurative  meningitis.  The  cardiac  symptoms  may  be  very  obscure, 
and  the  occurrence  of  embolism  during  a  febrile  process  be  the  first 
sign  to  explain  their  meaning.  Rigors  are  common,  and  are  the  cause 
of  malignant  endocarditis  being  frequently  mistaken  for  malarial  fevers. 
High  fever  is  the  rule,  and  is  an  important  element  in  the  diagnosis. 
But  I  have  met  with  instances,  proved  such  by  the  autopsy,  in  which 
fever  was  almost  absent. 

Acute  Pericarditis. — Acute  inflammation  of  the  serous  mem- 
brane of  the  exterior  of  the  heart  is  very  similar  to  that  of  its  interior. 
It  is  developed  under  the  same  circumstances.  It  is  found  in  rheu- 
matism, in  gout,  in  Bright's  disease,  in  scurvy,  in  alcoholism,  in  scar- 
let fever,  in  septic  processes,  or  as  an  extension  of  inflammation  from 
pleuro-pneumonia  ;  it  is  very  rarely  idiopathic.  The  pericardial  mal- 
ady exhibits  the  same  frequent  association  with  rheumatism  as  the 
endocardial  malady ;  it  presents  the  same  symptoms.  Nature  has 
not,  indeed,  drawn  a  very  strict  line  of  demarcation  between  the  two 
diseases.  When  one  exists,  the  other  is  very  apt  to  attend  it.  Yet 
we  do  meet  with  endocarditis  without  pericarditis,  and  more  often 
still  with  pericarditis  without  endocarditis. 

The  anatomical  effects  of  inflammation  of  the  pericardium  are  like 
those  of  acute  pleurisy.  The  pericardium  becomes  injected  and  dry  ; 
plastic  lymph  accumulates  on  its  surfaces,  and  especiahy  on  the  sur- 
face which  fits  tightly  around  the  heart.  This  stage  of  the  disease 
corresponds  to  the  dry  stage,  or  plastic  stage,  of  acute  pleurisy.  It 
may  have  the  same  termination  by  the  two  roughened  surfaces  ad- 
hering.    But  it  is  often  followed  by  a  stage  of  effusion.     The  effusion 


'  Lancereaux,  Arch.  Gen.  de  Med.,  April,  1881. 


400 


MEDICAL  DIAGNOSIS. 


may  remain  stationary  or  be  absorbed,  and  the  rugged  portions  of 
the  membrane  be  placed  again  in  apposition. 

The  characteristic  sign  of  the  plastic  stage  is  a  friction  sound.  Yet 
the  friction  sound  is  not  always  the  same  in  extent  or  in  character, 
because  the  deposited  •  lymph  is  not  always  the  same  in  extent  or  in 
character.  The  sound  is  like  the  crumpling  of  parchment,  or  the 
creaking  of  new  leather,  or  it  is  grazing,  or  like  a  series  of  irregular 
clicks.  It  is  single  or  double,  and  is  prone  to  mask  the  natural  sounds 
of  the  heart.  But  these  are  all  points  which  have  been  already  de- 
scribed :  we  shall  merely  add  that  when  the  friction  develops  itself 

Fig.  45. 


Illustration  of  the  position  of  the  heart  in  pericarditis,  and  of  the  distention  of  the  pericardium 
with  fluid.  The  heart-sounds  are  indistinct,  except  above  the  effusion ;  the  impulse  is  feeble.  The 
extent  and  shape  of  the  percussion  dulness  may  be  judged  of  by  the  appearance  of  the  distended  sac. 

under  our  observation,  and  with  signs  of  excitement  of  the  heart,  it  is 
as  distinctive  of  inflammation  of  the  pericardium  as  a  recent  blowing 
sound  is,  under  the  same  circumstances,  distinctive  of  inflammation 
of  the  endocardium.  When  the  pericardial  effusion  takes  place, 
it  ceases ;  but  only  gradually,  and  not  always  completely ;  and  in 
any  case  it  is  not  uncommon  for  the  ear  still  to  recognize  the  friction 
sound  at  the  base  of  the  heart  and  around  the  origin  of  the  great 
vessels. 

The  percussion  dulness  due  to  the  effusion  is  generally  consider- 
able ;  and  its  contour  is  characteristic.     When  the  patient  is  in  the 


DISEASES  OF  THE  HEART.  40] 

erect  posture,  it  is  pyramidal ;  when  he  Hes  on  his  back,  or  changes 
from  side  to  side,  the  outline  of  tlie  flat  sound  is  somewhat  altered. 
Rotch,^  in  an  elaborate  inquiry  into  the  matter,  points  to  the  dulness 
in  the  fifth  intercostal  space  to  the  right  of  the  sternum  as  occurring 
even  in  small  effusions ;  and  Roberts,^  in  his  excellent  monograph, 
speaks  of  the  valuable  aid  afforded  by  it  to  surgeons  about  to  tap  the 
pericardium.  Another  significant  sign  connected  with  the  dulness  is 
that,  as  Ramberger  has  taught  us,  an  area  of  dulness  near  the  angle 
of  the  scapula  which  coexists  with  bronchial  breathing  and  increased 
fremitus,  and  which  is  perceived  when  the  patient  is  erect,  is  greatly 
influenced  by  position.  It  disappears,  and  with  it  the  other  signs 
mentioned,  as  he  leans  forward,  to  return  as  the  erect  posture  is 
resumed. 

In  cases  of  considerable  effusion,  the  intercostal  spaces  of  the 
cardiac  region  widen,  the  eye  recognizes  a  distinct  bulging,  and  the 
dulness  on  percussion  reaches  far  upward,  to  the  second,  or  even  to 
the  first,  rib.  Within  the  space  of  dulness  is  sometimes  seen  an  irreg- 
ular, wavy  motion ;  and  what  the  eye  detects  the  hand  feels.  But 
no  movements,  or  only  slight  movements,  may  be  perceptible  in  the 
praecordia.  The  heart,  with,  its  point  pushed  upward  and  outward 
by  the  accumulating  liquid,  has  to  struggle  to  reach  the  walls  of  the 
chest.  Its  contractions  are  irregular ;  its  impulse  is  feeble,  or  all 
appreciable  impulse  has  ceased.  The  sounds  heard  through  the 
mass  of  fluid  seem  distant  and  muffled.  Yet  the  second  sound  over 
the  upper  part  of  the  sternum  and  at  the  base  of  the  heart  retains 
its  sharpness. 

During  the  stage  of  absorption  the  apex  returns  to  its  natural  posi- 
tion ;  the  dulness  gradually  disappears ;  the  sounds  and  the  impulse 
regain  more  of  their  normal  character ;  the  friction  murmur  reap- 
pears, and  then  ceases,  leaving  not  infrequently  the  two  surfaces  of 
the  pericardium  adhering. 

We  cannot  foretell  how  long  it  will  take  the  disease  to  run  through 
its  different  stages.  Death  may  occur  in  less  than  thirty  hours,  the 
heart  being  paralyzed  by  an  enormous  efi'usion ;  on  the  other  hand, 
the  acute  attack  may  last  for  as  many  days,  and  then  leave  serious 
traces.  But  whatever  stage  the  malady  be  in,  it  can  be  recognized 
only  by  the  physical  signs :  by  the  friction,  the  peculiar  percussion 
dulness,  the  enfeebled  impulse  and  heart-sounds. 

^  Boston  Med.  and  Surg.  Journ.,  1878,  vol.  xcix. ;  also  article  "Diseases  of  the 
Pericardium,"  in  Keating's  Cyclopa3dia  of  the  Diseases  of  Childi-en,  vol.  ii. 
^Paracentesis  of  the  Pericardium,  Phila. ,  1880. 


402  MEDICAL  DIAGNOSIS. 

There  are  no  general  symptoms  that  prove  a  pericarditis  to  exist. 
There  are  symptoms  by  which  we  may  infer  that  pericarditis  is 
present ;  but  there  are  none  Avliich  absolutely  belong  to  it  and  would 
prevent  it  from  being  overlooked.  The  symptoms  usually  met  with 
are  those  of  inflammation  of  the  endocardium,  but  with  more  decided 
local  evidence  of  disorder.  We  find  the  anxious  expression ;  the 
fever,  not  generally  high  ;  the  oedema  ;  the  same  uncertain  or  irregular 
pulse.  But  there  is  more  pain  over  the  heart, — acute,  severe  pain, 
shooting  to  the  left  shoulder,  augmented  by  movement,  increased  by 
pressure,  and  associated  with  epigastric  tenderness  ;  there  is  more 
dyspnoea,  because  the  cUstended  sac  presses  on  the  lung ;  a  dry,  irri- 
tative cough  ;  and  sometimes  difficulty  m  swallowing.  Yet  everj'  one 
of  these  symptoms  may  be  alDsent.  The  pulse  may  be  regular ;  the 
breatliing  not  perceptil3ly  accelerated  or  laborious  ;  and  even  the  im- 
portant symptom  of  pam,  though  this  is  rare,  may  be  wanting  from 
the  beginning  to  the  end  of  the  disease. 

When  the  action  of  the  heart  grows  weaker  and  weaker,  the  circu- 
lation becomes  more  irregular.  The  beat  of  the  arierj  at  the  wrist  is 
feeble,  and  intermits  ;  the  veins  of  the  neck  are  prominent ;  the  skin 
is  cold  and  pale  ;  the  extremities  are  CBdematous.  These  are  always 
symptoms  of  grave  import. 

If  next  we  incjuire  with  what  complaints  acute  pericarchtis  is 
likely  to  be  confounded,  inflammation  of  the  endocarchum  and  inflam- 
mation of  the  pleura  occur  at  once  to  the  mind.  To  contrast  the 
signs  of  the  first  two  maladies,  for  the  slight  difference  in  their  symp- 
toms has  already  been  mentioned  : 

Endocarditis.  Pericarditis. 

Blowing   sound ;    excited    action  of  the  Friction    sound  ;    excited    action    of  the 

heart.  heart. 

Shght,    if    any,    increase    of  percussion  In    stage  of  effusion,    marked    and    ex- 

dulness.  tended  percussion  dulness. 

Impulse  strong.  Impulse  wa\"y  and  feeble. 

Sounds  normal  or  more  distinct,  except  Sounds    feeble    and    muffled,    except    at 

at  site  where  murmur  is  heard.  base  ;  no  blowing  sound. 

Such  is  the  distinction  of  pure  cases  of  each  disease.  Still,  as 
already  stated,  the  affections  are  often  combined.  It  is  not  uncom- 
mon to  hear  ^dth  the  friction  sound  a  distinct  endocardial  murmur. 
But  there  is  sometimes  a  cUfficulty  of  another  kind  in  the  way  of  a 
precise  diagnosis.  The  murmur  produced  on  the  outside  of  the 
heart  may  simulate  so  closely  the  murmur  produced  m  its  interior 
that  it  is  almost   impossible   to    discriminate   between   them.      The 


DISEASES  OF  THE  HEART.  403 

former  may  completely  possess  the  blowing  characters  of  the  latter. 
Mostly,  however,  it  is  rougher ;  more  prone  to  be  double ;  and  each 
division  is  like  the  other,  equally  rough,  equally  superficial-sounding, 
equally  lacking  in  strict  correspondence  to  the  systole  or  to  the 
diastole.  And,  above  all,  the  sound  alters  at  times  both  in  situation 
and  in  character  with  amazing  rapidity.  Perceived  now"  as  an  ordi- 
nary bellows  murmur  on  the  left  side,  it  is  after  the  lapse  of  some 
hours  heard  as  a  rough  rasping  sound  on  the  right.  These  changes 
have  a  high  degree  of  value.  But  they  are  not  of  constant  occur- 
rence ;  and  to  say  that  it  is  sometimes  impossible  to  tell  a  pericardial 
from  an  endocardial  sound  is  to  say  no  more  than  is  borne  out  by 
every-day  experience.  In  the  stage  of  effusion  pericarditis  is  not 
likely  to  be  mistaken  for  endocarditis. 

Pleurisy  gives  rise  to  some  of  the  same  symptoms  and  signs 
as  pericarditis.  It  develops  a  friction  sound ;  it  occasions  dulness 
on  percussion,  dyspnoea,  and  cough.  But  the  physical  signs  are  in 
different  situations.  In  the  one  disorder  they  are  in  the  region 
of  the  heart,  and  are  confined  there  ;  in  the  other,  they  are  spread 
over  the  whole  side  of  the  chest,  and  are  most  perceptible  at*  the 
back.  This  is  true  of  the  dulness,  and,  for  the  most  part,  of  the 
friction  sound,  which,  when  of  pericardial  origin,  is  rarely  heard 
posteriorly. 

At  times,  however,  we  meet  with  very  puzzling  cases.  A  friction 
sound  discerned  over  the  heart  may  be  in  reality  produced  in  the 
adjoining  pleura.  The  patient  is  directed  to  suspend  his  breathing ; 
the  friction  sound  does  not  stop.  Now,  the  inference  from  this  would 
be  that  the  sound  originates  in  the  pericardium ;  and  in  the  large 
majority  of  instances  this  is  a  correct  inference.  But  it  is  not  always 
so.  The  friction  may  have  its  seat  in  the  pleura  and  be  caused  by  the 
movements  of  the  heart.  There  are  no  absolute  means,  besides  the 
intermission  of  the  sound  during  some  of  the  beats  of  the  heart,  as 
well  as  diuingsome»of  the  acts  of  breathing,  especially  in  expiration, 
of  detecting  in  these  rare  cases  the  true  seat  of  the  disease.  Then, 
both  in  pleuro-pneumonia  and  in  phthisis  there  may  be  a  pleiiro- 
pericardial  friction,  from  an  attending  pericarditis.  It  also  is  much 
influenced  by  the  respiratory  acts.  During  deep  iaspfration  it  lessens 
or  disappears  ;  expfration  intensifies  it. 

To  confound  the  dulness  on  percussion  caused  by  liquid  in  the 
pericardium  with  that  due  to  liquid  in  the  pleu7xi,  is  a  mistake  the 
more  likely  to  happen,  because  the  two  serous  membranes,  and  indeed 
the  lung,  are  often  involved  in  the  same  inflammation.  But  a  peri- 
carditis uncomplicated  with  pleurisy  or  with  pleuro-pneumonia  does 


404  MEDICAL  DIAGNOSIS. 

not  change  the  clear  sound  at  the  back  of  the  chest  save  m  rare  cases 
of  enormous  accumulation  of  fluid.  Effusion  into  the  pleura  gives 
rise  to  a  flat  sound  anteriorly ;  to  a  still  more  perceptible  dulness  at 
the  inferior  portion  of  the  chest  posteriorly ;  and  the  sounds  of  the 
heart  remain  unaltered. 

These,  then,  are  the  diseases  with  which  acute  pericarditis  is  liable 
to  be  confounded.  There  are  several  chronic  cardiac  maladies  which 
will  occasion  some  of  the  same  signs  and  symptoms  :  such  are  thin- 
ning of  the  ventricles  with  distention  of  the  cavities,  and  a  dropsy  of 
the  pericardium.  But  the  history  of  these  affections  is  different,  and 
their  signs,  although  similar,  are  not  precisely  the  same.  The  dropsy 
of  the  pericardium  is  associated  mth  dropsies  elsewhere,  and  with 
some  obvious  cause  accounting  for  the  watery  effusion,  and  at  no 
stage  of  its  existence  does  it  exhibit  a  friction  sound,  while  albumin 
in  the  urine,  oedema  of  the  lungs,  or  hydrothorax  are  common  at- 
tendants. A  double  friction  sound  at  the  right  base  may  cause  a 
plastic  pericarditis  to  be  mistaken  for  aortic  regurgitation.  But  the 
marked  coexisting  hypertrophy  in  this  affection,  the  imchanging  char- 
acter of  the  abnormal  sounds,  and  the  peculiar  pulse,  guard  against 
error. 

There  is  another  complaint  of  which  pericarditis  sometimes  bor- 
rows the  garb.  The  thoracic  symptoms  may  be  latent,  but  the  dis- 
ease may  produce  the  symptoms  of  extreme  gastric  irritation  or 
inflammation.  Nausea  and  vomiting  are  marked,  and  tenderness  on 
pressure  in  the  epigastric  region.  All  the  remedies  are  directed  to 
the  stomach  ;  and  at  the  post-mortem  examination  the  physician  stands 
amazed  at  finding  this  discus  healthy  and  the  pericardium  full  of 
serum  or  pus.  An  inquiry  into  the  state  of  the  heart  might  have 
saved  him  from  a  serious  blunder. 

Another  grave  error  which  may  be  thus  obviated  is  the  mistaking 
of  some  cases  of  acute  pericarditis,  on  account  of  the  wild  delirium 
they  present,  for  acute  inflammation  of  the  brain.  A'ow,  both  in  endo- 
carditis and  in  pericarditis  this  active  delirium  may  throw  all  the  other 
symptoms  into  the  background.  It  is  difficult  to  see  Avhy  a  pericardial 
inflammation  should  give  rise  to  such  violent  disturbance  of  the  brain. 
It  is  not  at  all  unlikely  that  it  has  its  origin,  in  part,  at  least,  in  the 
contaminated  state  of  the  blood  which  occurs  in  the  affections,  as 
rheumatism  or  Bright's  disease,  with  which  pericarditis  is  often  asso- 
ciated. However  occasioned,  it  is  necessary  to  be  aware  that  the 
cerebral  symptoms  arising  in  inflammation  of  the  membranes  of  the 
heart  may  entirely  draw  off  attention  from  the  serious  lesions  within 
the  chest.     A  fixed  delusion  of  having  committed  some  crime  appears 


DISEASES  OF  THE  HEART.  405 

to  Flint  ^  to  be  a  distinguishing  feature  of  the  mental  wandering ; 
while  Sibsbn  ^  in  his  exhaustive  analysis  points  out,  what  I  have  known 
to  happen  in  more  than  one  instance,  that  the  desponding  and  taciturn, 
or,  as  he  calls  it,  sombre  delirium  lasts  from  two  or  three  weeks  to  as 
many  months. 

Can  we  by  the  symptoms  or  physical  signs  tell  the  character  of 
the  fluid  in  the  sac  ?  We  cannot  by  the  signs  ;  and  by  the  symptoms 
we  can  only  suspect  pus  if  there  be  recurring  chills,  and  irregular  but 
high  temperature,  and  if  the  pericarditis  have  arisen  in  the  course  of 
a  malady  that  makes  the  presence  of  pus  likely.  Hemorrhagic  peri- 
carditis can  also  only  be  distinguished  as  a  probability  by  the  history. 
It  happens  in  scurvy  and  in  purpura,  and  may  be  an  attendant  upon 
tubercle  or  cancer  of  the  pericardium.  Cancerous  pericarditis  pro- 
duces also  serous  or  purulent  effusion.  It  is  never  a  primary  disease, 
and  it  has  no  characteristic  symptom,  except  it  be,  in  some  cases, 
darting  pain  in  the  praecordial  region  attending  the  signs  of  peri- 
carditis. It  is  by  the  history  and  the  evidence  of  deposit  elsewhere 
that  we  have  to  judge.  The  same  is  true  of  tubercular  pericarditis. 
Here  the  pericarditis  is  often  dry,  and  the  membrane  much  thickened. 
Yet  an  enormous  effusion  may  occur,  as  happened  in  a  case  recorded 
by  Musser.'^ 

Let  us  now  inquire  in  how  far  one  of  the  terminations  (^f  pericar- 
ditis by  adhesion  or  agglutination  of  the  surfaces  can  be  recognized. 
In  many  of  such  cases,  whether  there  be  coexisting  dilatation,  or 
hypertrophy,  or  what  is  most  common,  combined  dilatation  and  hy- 
pertrophy, we  find  changed  rhythm  and  dyspnoea,  oedema  of  the 
extremities,  and  syncopal  attacks.  Yet  these  are  not  special  signs 
of  pericardial  adhesion.  Indeed,  there  is  not  a  single  symptom  or 
sign  constant,  or  by  itself  characteristic  of  pericardial  adhesion.  The 
most  trustworthy  signs  are  a  drawing  in  of  the  apex  of  the  heart 
during  the  contraction  of  the  ventricles,  with  a  depression  in  the  inter- 
costal spaces  becoming  visible  at  the  same  time,  and  sometimes  with 
a  simultaneous  sinking  in  at  the  lower  half  of  the  sternum ;  the  limits 
of  the  increased  dull  percussion  sound  in  the  praecordial  region  re- 
maining unaffected  during  inspiration  and  expiration ;  a  fixed  apex 
beat,  uninfluenced  by  change  of  posture  of  the  body  or  by  the  acts  of 
breathing ;  diminution  of  the  inspiratory  movements  in  and  near 
the  epigastrium ;  greatly  extended  undulatory  impulse  ;  and  diastolic 

'  Diseases  of  the  Heart. 

^  Article  "Pericarditis"  in  Reynold's  System  of  Medicine. 

^  Medical  Diagnosis, 


406  MEDICAL  DIAGNOSIS. 

rebound  felt  on  placing  the  hand  over  the  seat  of  the  impulse. 
Enfeeblement  or  absence  of  impulse,  while  it  may  happen,  is  much 
rarer.  A  sign  of  value  is  the  one  pointed  out  by  Broadbent,  a  draw- 
ing in  with  the  systole  of  the  posterior  and  lateral  walls  of  the  chest, 
generally  most  evident  between  the  eleventh  and  twelfth  ribs,  and 
indicative  of  universally  adherent  pericardium.  Duroziez^  attaches 
importance  to  the  nipple  being  kept  in  constant  motion.  Friedreich^ 
dwells  on  a  rapid  emptying  of  the  veins  of  the  neck  during  the 
diastole  of  the  heart,  while  with  the  systole  they  swell  up ;  and 
Riess  ^  tells  us  that,  owing  to  the  close  bringing  together  of  the  heart, 
diaphragm,  and  stomach,  the  heart-sounds  resound  mth  a  metallic 
ring.  The  heart-sounds,  owing  to  the  frequent  association  of  ad- 
herent pericardium  with  valve  affections,  may  be  replaced  by  mur- 
murs. To  the  occurrence  of  a  presystolic  murmur,  Hale  White  has 
called  special  attention.  When  the  pericardial  surfaces  are  exten- 
sively and  firmly  united,  the  eye  is  struck  by  the  e^ddent  depression 
of  the  praecordial  region.  When  the  pericardium  is  adherent  to  the 
sternum  and  bands  pass  off  compressing  the  aorta,  "  indurated  medi- 
astino-pericarditis,"  a  pulse  vanishing  with  each  full  inspiration — 
pulsus  paradoxus — has  been  described  by  Kussmaul.^  The  same  sign 
has  been  noticed  by  Irvine  in  cases  of  adherent  pericardium  and 
pleura,  and  by  Traube  ^  in  exudative  pericarditis  where  the  medias- 
tinum was  not  implicated.  Aran  has  proved  the  tendency  to  sudden 
death  in  complete  pericardial  adhesion. 

Closely  connected  with  the  subject  of  inflammation  of  the  peri- 
cardium is  that  rare  affection  in  which  air  is  present  in  the  pericardial 
ca^fitj,  jmeiimo-jDericardium,  or,  more  strictly  speaking,  on  account  of 
the  frequent  association  with  finid,  pneiimo-hydropericardium.  It  oc- 
curs as  the  result  of  injuries,  of  communication  established  by  disease 
between  the  pericardium  and  the  neighboring  organs,  and  in  very  ex- 
ceptional mstances  is  due  to  decomposition  of  hquids  in  the  sac.  Its 
chief  diagnostic  features  are  abnormal  resonance  over  the  cardiac 
region,  and  a  metallic  character  of  the  heart-sounds.  The  tympanitic 
resonance  alters  in  a  most  marked  manner  with  changes  in  the  posture 
of  the  patient,  and  is  limited  by  a  distinct  line  of  dulness  caused  by 
the  fluid.  The  metallic  sounds  may  at  times  be  heard  at  a  distance, 
and  may  be  attended  with  sounds  of  most  extraordinary  kind,  friction 

^  Traite  clinique  des  Maladies  du  Coeur. 

^  Virchow's  Archiv,  Bd.  xxix. 

2  Berliner  klinische  Woclienschrift,  No.  51,  1878. 

Mbid.,  No.  37,  1873. 

■"  Charite  Annalen,  1876. 


DISEASES  OF  THE  HEART.  407 

sounds  mixed  with  splashing  and  gurghng,  the  so-called  water-wheel 
sound,  the  bruit  de  moulin;  generally  an  intermittent  sound,  at  first 
metallic.  The  cardiac  impulse  is  feeble  or  absent.  The  symptoms 
of  pneumo-pericardium  are  vague,  generally  those  of  a  pericarditis, 
with  great  difficulty  in  breathing,  high,  fluctuating  temperature,  chest 
pain,  and  failing  circulation.  In  point  of  diagnosis  we  must  be  care- 
ful not  to  be  misled  by  the  modification  of  the  cardiac  sounds  and 
the  splashing  and  metallic  phenomena  due  to  a  dilated  stomach. 
From  pneumothorax,  even  when  encapsulated  near  the  heart,  we  dis- 
tinguish pneumo-pericardium  by  the  dulness  on  percussion  to  be 
found  over  the  displaced  heart  in  the  former  malady,  and  the  am- 
phoric or  metallic  respiratory  sounds  that  are  heard  in  addition  to  the 
metallic  heart-sounds. 

The  discovery  by  Welch  of  the  bacillus  aerogenes  capsulatus,  and 
its  association  with  gas  forming  in  the  tissues  and  cavities,  will  explain 
instances  of  pneumo-pericardium  following  wounds.  The  entrance 
of  air  may  happen,  as  in  the  cases  of  Meigs  ^  and  of  Miiller,^  by  a 
rupture  brought  about  by  the  pericardial  exudation, — in  the  one  case 
into  the  oesophagus,  in  the  other  into  the  lung.  These  cases  of  ulcer- 
ative perforation  almost  all  end  fatally. 

Myocarditis. — Of  inflammations  of  the  substance  of  the  heart 
there  are  two  chief  varieties, — the  acute  inflammation  of  the  muscu- 
lar walls,  and  the  chronic  myocarditis  or  fibroid  degeneration.  The 
acute  gives  rise  to  infiltration  between  the  fibres  of  the  heart  of  blood- 
corpuscles,  of  proliferating  cells,  and  of  leucocytes,  and  the  muscular 
fibres  themselves  become  granular  and  degenerate.  Local  softening 
and  circumscribed  abscess,  and  even  gangrene  and  perforation  of  the 
ventricle  may  result.  But  we  are  not  enabled  to  foretell  the  state 
of  the  heart  during  life,  mainly  because  the  muscular  structure  is 
rarely  affected  without  the  endocardium,  or  still  more  frequently  the 
pericardium,  being  implicated,  and  thus  the  manifestations  of  these  dis- 
orders occur  mixed  with  those  of  the  myocarditis.  Great  pain  in  the 
cardiac  region  is  the  most  usual  and  the  most  prominent  of  the  symp- 
toms. The  breathing  is  generally  much  oppressed ;  delirium  is  often 
present ;  the  urine  is  scanty  and  albuminous  ;  the  heart  fails  in  power ; 
and  the  patient  dies  in  a  state  of.  utter  prostration  or  sufl'ocates  from 
pulmonary  oedema.  The  pulse,  as  in  endocarditis  or  in  pericarditis, 
exhibits  no  uniform  character.  The  statement  that  it  is  invariably 
intermittent,  feeble,  and  quick,  is  not  correct.     It  is  so  as  the  disease 


^  Amer.  Journ.  Med.  Sci.,  Jan.  1875. 

^  Deutsches  Archiv  flir  klinische  Medicin,  Bd.  xxiv.,  1879. 


408  MEDICAL  DIAGNOSIS. 

advances,  but  it  may  be  full,  and  not  above  eighty,  long  after  the 
distress  in  the  chest  is  unbearable.^  The  temperature  may  be  only 
slightly  elevated  or  very  high.  The  signs  of  cardiac  failure  are  quickly 
developed.  The  heart-sounds  are  weak  and  irregular,  and,  owing  to 
acute  dilatation  occurring,  the  cardiac  dulness  increases.  In  purulent 
myocarditis  the  temperature  shows  marked  remissions  and  exacerba- 
tions, and  rigors  and  sweatings  are  usual. ^  Acute  myocarditis  may 
occur  in  rheumatism,  but  it  is  most  common  in  pysemia  and  in 
phlebitis.  Its  occasional  association  with  gonorrhoea  has  been  pointed 
out,  and  it  may  be  found  with  or  without  gonorrhoeal  rheumatism.^ 
In  children  there  is  a  distinctly  cerebral  form.* 

Acute  interstitial  myocarditis  and  parenchymatous  myocarditis, 
the  muscular  fibres  in  both  being  infiltrated  with  granules,  have  no 
distinctive  symptoms.  They  occur  in  fevers,  particularly  in  typhoid 
fever,  yellow  fever,  and  smallpox,  and  in  pericarditis,  and  may  be 
suspected  under  these  circumstances  from  the  feeble  heart  action. 

Chronic  myocarditis^  or  fibroid  degeneration,  often  results  from 
rheumatism,  or  attends  pseudo-hypertrophic  paralysis.  A  very  com- 
mon cause  is  disease  of  the  coronary  arteries,  especially  obliterating 
endarteritis  of  syphilitic  origin.  The  disease  is  most  comnion  in  men, 
and  may  lead  to  aneurism  of  the  heart.  The  diagnosis  of  chronic 
myocarditis  is  as  uncertain  as  that  of  the  acute  form.  The  symptoms 
are  those  of  a  feeble  heart :  oedema,  breathlessness  on  exertion,  cough, 
hemorrhages  into  different  organs,  venous  congestions,  hydrothorax, 
occur.  In  some  cases  there  is  pain  over  the  heart  or  marked  anginous 
attacks  occur.  The  percussion  dulness  in  the  cardiac  region  is  some- 
what increased,  and  the  heart  is  generally  dilated,  or  in  a  state  of 
combined  dilatation  and  hypertrophy.  The  first  sound  is  indistinct, 
or  there  is  a  mitral  systolic  murmur  ;  the  second  over  the  aorta  is 
apt  to  be  accentuated  or  doubled.  A  significant  sign  is  a  want  of 
correspondence  between  the  heart  and  the  pulse-beats  ;  these  are 
unequal  and  irregular.'^  Some  stress  may  be  laid  on  signs  of  peri- 
cardial adhesion,  if  present. 

^  Salter,  Medico-Chirurgical  Transactions,  vol.  xxii.  In  several  of  the  cases 
on  record,  for  instance  in  the  one  mentioned  by  Graves  in  his  Clinical  Lectures, 
there  was  coexisting  valvular  disease,  which,  of  course,  invalidates  the  statements 
as  regards  the  character  of  the  pulse,  and,  indeed,  as  regards  many  of  the  other 
symptoms. 

^  Bramwell,  Diseases  of  the  Heart,  Edinb.,  1884. 

^  Councilman,  Amer.  Journ.  Med.  Sci.,  Sept.  1893. 

*  Mitchell  Bruce,  Keating' s  CyclopaBdia  of  the  Diseases  of  Children,  vol.  ii. 

5  Ruble,  Archiv  fur  klin.  Med.,  1878. 


DISEASES  OF  THE  HEART.  409 

Chronic  Diseases  attended  with  Increased  Extent  of  Percus- 
sion Dulness,  but  with  Normal  or  ahnost  Normal  Heart- 
Sounds. 

To  this  group  belong  those  diseases  which  affect  the  walls  of  the 
heart  or  its  cavities,  without  having  involved  the  valvular  apparatus, 
such  as  hypertrophy  and  dilatation, — types  of  the  two  different  states 
of  force  and  of  weakness,  but  both  exhibiting  an  extent  of  percussion 
dulness  greater  than  in  health,  and  heart-sounds  not  materially 
changed. 

Hypertrophy. — Hypertrophy  of  the  heart  is  an  overgrowth  of  its 
walls,  and  usually  also  of  its  cavities  ;  for,  although  we  may  have 
the  muscle  thickening  without  the  cavity  enlarging,  nay,  even  with 
it  diminishing  in  size,  neither  this  simple  nor  the  concentric  hyper- 
trophy occurs,  save  in  rare  instances.  It  is  evident  that  any  one  of 
the  chambers  of  the  heart  may  alone  become  hypertrophied.  But, 
practically,  the  state  we  mean  when  speaking  of  cardiac  hypertrophy 
is  an  increase  of  the  ventricles,  and  especially  of  the  left  ventricle,  in 
its  wall  and  cavity,  with  a  similar,  although  much  slighter,  expansion 
of  the  right  side. 

The  physical  and  vital  manifestations  of  the  heart  having  out- 
grown its  natural  dimensions  are  these :  The  pulse  is  full  and  strong, 
and  somewhat  tense.  The  face  is  florid,  or  else  it  is  pale ;  and  the 
mucous  membranes  of  the  lips  and  eyelids  are  injected.  The  eyes 
are  bright,  and  apt  to  be  prominent.  The  carotids  pulsate  forcibly 
under  the  least  excitement.  Some  persons  suffer  from  headache  and 
giddiness  ;  in  fact,  all  the  symptoms  denote  a  circulation  actively — too 
actively — carried  on.  Yet  the  symptoms  directly  referable  to  the  heart 
are  not  marked.  There  is,  as  a  rule,  no  pain  or  irregular  action  of 
the  heart,  nor  do  violent  fits  of  palpitation  occur.  What  the  patient 
comes  to  consult  his  physician  about  are  rushes  of  blood  to  the  head ; 
or  a  ringing  in  the  ears ;  or  a  feeling  of  weight  in  the  epigastrium 
which  troubles  him  after  a  full  meal ;  or  shortness  of  breath ;  or  in 
consequence  of  the  powerful  action  of  the  heart,  when  lying  in  bed, 
attracting  his  attention ;  or  because  he  is  alarmed  about  a  dry  cough, 
and  believes  himself  the  victim  of  pulmonary  consumption. 

The  physical  signs  are  more  .uniform  than  the  symptoms.  We 
observe  a  fulness  or  arching  of  the  prsecordial  region,  and  an  impulse, 
strong,  heaving,  and  extended  over  several  intercostal  spaces.  The 
apex  does  not  strike  the  chest  walls  between  the  fifth  and  sixth  ribs, 
but  its  beat  is  perceived  .lower  down,  usually  an  inch  or  more  to  the 
outside  of  the  nipple  line.    The  extent  of  percussion  dulness  increases, 


410 


MEDICAL  DIAGNOSIS. 


both  longitudinally  and  transversely;  and  particularly  in  the  latter 
direction,  if  the  right  ventricle  be  much  enlarged.  This  peculiarity  in 
the  expansion  of  the  area  of  dulness  on  percussion  forms,  in  truth, — 
With  the  greater  dyspnoea,  and  with  an  impulse  more  directly  per- 
ceived over  the  right  side  of  the^  heart,  near  the  pit  of  the  stomach, 
and  often  out  of  proportion  to  the  compressible  and  rather  small 
radial  beat,  and  with  the  increased  distinctness  of  the  second  sound 
of  the  pulmonary  artery,— the  sign  that  hypertrophy  with  dilatation 
has  principally  affected  the  right  side. 

Fig.  46.       ' 


An  hypertrophied  heart  lying  in  its  position  in  the  chest.  The  cause  of  the  lowered  apex  beat, 
and  of  the  extension  of  the  impulse,  as  well  as  of  the  somewhat  squarer  outline  of  the  increased 
dulness  over  the  enlarged  organ,  is  obyious  from  the  shape  and  position  of  the  heart. 


The  first  sound  of  an  hypertrophied  heart  is  duller  than  in  health, 
but  prolonged  and  weighty.  The  second  sound  is  not  particularly 
changed.  There  are  no  murmurs,  except  under  rare  circumstances, 
which  will  be  mentioned  in  discussing  valvular  diseases.  Thus,  the 
greatest  value  of  auscultation  is  that,  by  showing  the  sounds  but  little 
altered,  it  enables  us  positively  to  exclude  a  lesion  of  the  valves  ;  just 
as  the  chief  service  of  percussion,  with  reference  to  an  enlarged  heart, 
consists  in  permitting  us  to  distinguish  the  excited  motions  of  the  sim- 
ply disturbed  organ  from  the  action  of  a  heart  the  walls  of  which  are 


DISEASES  OF  THE  HEART.  411 

thickened  ;  and  as  the  main  use  in  noting  the  impulse  is  tliat  it  serves 
as  a  means  of  discrimination  between  hypertrophy  and  those  affections 
in  which  the  beat  is  weakened,  such  as  dilatation  or  a  pericardial 
effusion,  or  between  the  dulness  in  the  prsecordial  region  due  to 
hypertrophy  and  that  caused  by  deposits  in  the  pleura,  in  the  medias- 
tinum, or  in  the  lung.  Where  there  is  contraction  of  the  left  lung,  as 
from  pleurisy  or  fibroid  change,  more  of  the  heart  is  exposed,  and  the 
dulness  on  percussion  in  the  cardiac  region  is  increased,  as  well  as  the 
impulse,  which  is  felt  over  a  larger  space  and  to  the  left ;  but  the  car- 
diac sounds  are  unchanged,  and  deep  inspiration  alters  the  extent  of 
cardiac  dulness  but  little. 

Hypertrophy  may  be  combined  with  decided  dilatation  of  the 
heart.  This  kind  of  hypertrophy  presents  a  less  dull,  prolonged  first 
.sound,  and  the  pulse,  though  full,  is  likely  to  be  more  compressible. 
Hypertrophy  may  affect  specially  any  part  of  the  constituents  of  the 
muscular  walls.  Thus,  the  connective  tissue,  as  Quain  has  particu- 
larly called  attention  to,  may  be  alone  concerned  in  the  morbid  action. 
Hypertrophy  of  the  heart  is  found  much  more  frequently  among 
males  than  among  females.  Its  causes  are  various.  It  is  common 
in  Bright's  disease  and  in  general  arterial  sclerosis ;  continued  func- 
tional excitement  produces  it ;  so  does  any  kind  of  strain  and  over- 
action,  and  perhaps  excessive  nourishment.  It  is  found  to  be  common 
among  inordinate  beer-drinkers.  But  the  main  cause  is  an  obstruc- 
tion to  the  circulation,  either  in  the  heart  or  in  other  organs.  It  is 
for  this  reason  that  the  complaint  is  so  often  met  with  in  connec- 
tion with  diseases  of  the  valves  or  of  the  large  arteries,  and  that  the 
right  side  of  the  heart  enlarges  when  the  pulmonary  air-vesicles  are 
over-distended.  We  also  encounter  hypertrophy  in  the  heart  as 
a  consequence  of  obliteration  of  the  pericardial  sac.  In  the  hyper- 
trophy of  chronic  nephritis  reduplication  of  the  first  sound  is  often 
noticed. 

There  is  a  form  of  hypertrophy  of  the  heart  to  which  attention 
has  been  particularly  called  by  Fothergill's  description, — the  so-called 
gouty  heart.  Generally  there  is  coexisting  chronic  contracting  kidney. 
In  the  first  stage  we  find  decided  hypertrophy  with  accentuation  or 
booming  of  the  second  aortic  sound,  high  blood-pressure,  tense  pulse, 
hardened  arteries,  and  the  passage  of  large  amounts  of  pale  urine  of 
low  specific  gravity.  The  renal  changes  may  or  may  not  be  evident ; 
we  may  or  may  not  detect  albumin  in  the  urme.  In  a  subsequent 
stage  of  the  malady  there  is  failure  of  the  circulation.  The  cardio- 
vascular phenomena  are  early  made  perceptible  by  the  sphygmograph. 
The  full,  tense  pulse  gives  a  full  up-stroke,  a  broad  summit,  and  a 


412  MEDICAL  DIAGNOSIS. 

retarded  down-stroke ;  the  "  square-headed  tracing"  formed  is  very 
characteristic  of  the  malady,  and  bespeaks  the  fibroid  change  in  the 
kidney,  whether  or  not  albumin  be  found.  In  some  instances  con- 
siderable cardiac  dilatation  as  well  as  hypertrophy  is  present.  The 
high  blood-pressure  is  due  to  the  waste-laden  blood.  The  skin  often 
exhibits  little  twigs  of  dilated  vessels ;  the  ear  is  usually  deep  red, 
with  a  large  glistening  lobe  ;  or  in  spare  persons  the  lobe  looks  with- 
ered ;  the  teeth  become  blunt  and  worn  down  in  time ;  the  hair  is 
apt  to  be  iron-gray.  There  is  the  history  of  gout,  acquired  or  heredi- 
tary, but  there  may  have  been  no  active  outbreak  of  gout,  rather  the 
condition  of  imperfect  assimilation  known  as  lithsemia. 

Dilatation. — Except  in  its  seat  in  the  ventricles,  dilatation  of  the 
heart  is  the  reverse  of  hypertrophy.  The  cavities  are  stretched  out 
of  all  proportion  to  the  thickness  of  the  muscular  walls  ;  these  may 
be  slightly  thicker  than  normal,  or  of  natural  thickness,  or  thinner, 
and  apparently  hardly  capable  of  supporting  the  weight  of  the  blood. 

Almost  opposite  symptoms  and  physical  signs  to  those  of  hyper- 
trophy result  from  dilatation.  In  place  of  activity  and  power,  every- 
thing indicates  inaction  and  stagnation.  There  is  a  very  strong  ten- 
dency to  venous  congestions  and  to  dropsies.  The  portal  system  is 
gorged.  The  liver  increases  in  size.  The  bowels  are  constipated. 
The  urinary  secretion  is  interfered  with,  and  sometimes  albumin  is 
passed.  The  hearing  may  become  dull.  The  patient  is  languid  and 
feeble,  and  his  intellect  obtuse.  He  suffers  from  chilly  sensations, 
and  from  uneasiness  in  the  cardiac  region  and  palpitations.  The  pulse 
is  small,  unequal,  and  irregular,  and  the  veins  of  the  surface  are 
swollen.  The  skin  around  the  ankles,  and  often  at  other  parts  of  the 
body,  pits  on  pressure.  But,  since  it  is  the  right  side  of  the  heart 
which  is  usually  the  most  affected,  the  lungs  show  most  plainly  the 
effects  of  the  venous  stagnation.  .Breathlessness  on  exertion  or  diffi- 
culty in  breathing,  making  itself  at  times  manifest  in  paroxysms 
attended  with  wheezing  respiration ;  a  chronic  cough ;  a  collection  of 
serum  in  the  pulmonary  structure, — all  add  to  the  misery  which  the 
perilous  malady  entails.  And  as  it  is  commonly  some  obstructive 
disease  in  the  lungs,  such  as  emphysema,  which  has  given  rise  to  the 
■dilatation  of  the  right  side  of  the  heart,  so  this  again  augments  the 
morbid  state  of  the  lungs,  and  aggravates  the  symptoms. 

The  physical  signs  are  very  unlike  those  of  hypertrophy.  The 
same  extended  dulness  on  percussion  exists  ;  but  it  is  associated  with 
a  feeble  and  fluttering  impulse,  which  is  in  strong  contrast  with  the 
heaving,  powerful  blow  of  an  hypertrophied  left  ventricle,  and  which 
at  times  cannot  be  localized,  or  may  be  seen,  yet  cannot  be  felt.     The 


DISEASES  OF  THE  HEART. 


413 


sounds  in  cardiac  dilatation  are  not  always  the  same.  When  the  walls 
are  thin,  they  are  clearer,  sharper,  and  more  ringing  than  in  health  ;  if, 
however,  the  muscular  structure  be  at  all  degenerated,  the  first  sound 
is  faint  and  very  ill  defined.  The  second  is  often  split,  giving  rise  to 
the  so-called  gallop  rhythm.  But  no  murmurs  are  perceived,  unless 
a  watery  state  of  the  blood  produces  them,  or  unless  it  happens — 
and  it  does  not  infrequently  happen— that  the  dilatation  of  the  heart 
is  conjoined  to  valves  incompetent,  either  temporarily  or  permanently, 
to  prevent  regurgitation. 

Fig.  47. 


A  dilated  heart,  the  right  ventricle  opened.  In  this  case  there  was  no  valvular  disease.  Hence 
the  characteristic  physical  signs;  the  increased  dulness  on  percussion,  the  extended  but  weak 
impulse.    The  first  sound  was  feeble,  for  the  organ  was  flabby  as  well  as  dilated. 


In  acute  dilatation  of  the  heart,  such  as  we  sometimes  see  in 
fevers,  or  in  pneumonia,  or  after  violent  exertion  and  strain,  or  from 
shock  or  sudden  fright,  or  where  an  hypertrophied  heart  suddenly 
fails  in  power,  we  have,  besides  the  symptoms  of  great  venous  con- 
gestion, dyspnoea,  and  rapid,  feeble  impulse,  or  impulse  irregular,  now 
strong,  now  weak,  temporary  systolic  murmurs  of  varying  site,  chiefly 
a  systolic  apex  murmur.  But  the  murmur  may  be  near  the  ensiform 
cartilage  over  the  tricuspid  area,  or,  as  in  a  case  observed  by  Broad- 
bent,^  over  the  pulmonary  artery. 


^  Heart  Disease,  p.  241. 
26 


414  MEDICAL   DIAGNOSIS. 

Dilatation  is  not  always  pure ;  it  is  met  with  in  every  possible 
degree,  and  in  combination  with  hypertrophy  and  valvular  diseases. 
Accordingly,  its  symptoms  and  signs  are  somewhat  dissimilar.  But 
one  constant  feature  it  preserves ;  it  always  holds  up  to  view  both 
the  vital  and  the  physical  manifestations  of  a  weak  heart.  Indeed, 
when  an  hypertrophied  heart  dilates,  the  signs  of  relative  weakness 
become  superadded,  the  impulse  is  not  so  strong  as  before  in  com- 
parison with  the  percussion  dulness,  and  dropsy  becomes  a  marked 
symptom.  Pure  dilatation  is  likely  to  be  confounded  with  the  dis- 
eases in  which  enfeebled  action  of  the  heart  is  encountered,  and  these 
are  fatty  degeneration  and  a  pericardial  effusion. 

Fatty  Degeneration. — This  is  one  of  those  disorders  with  the 
anatomical  characters  of  which  we  are  far  better  acquainted  than  with 
their  clinical  history.  There  is,  indeed,  no  sign  by  which  we  can 
positively  say  that  the  dangerous  disorganization  of  the  muscular 
fibres  of  the  heart  is  in  progress.  We  may,  however,  suspect  it,  if 
the  signs  of  weak  action  of  the  heart — feeble  impulse  and  ill-defined 
sounds,  especially  the  first  sound — coexist  with  oppression,  with  a 
tendency  to  coldness  of  the  extremities,  with  a  pulse  permanently 
slow  and  of  low  tension,  or  permanently  frequent,  empty  and  irregu- 
lar, or  rigid  though  weak,  and  be  met  with  in  a  person  who  is  the 
subject  of  a  wasting  disease,  or  has  arrived  at  a- time  of  life  at  which 
all  the  organs  are  prone  to  undergo  decay.  Somethmg  more  than  a 
probable  opinion  is  warranted  if,  in  addition,  there  be  proof  of  scle- 
rotic change  in  the  vessels,  or  of  fatty  degeneration  elsewhere,  such  as 
an  arcus  senilis ;  or  if  it  be  ascertained  that  the  patient  suffers  from 
pain  across  the  upper  part  of  the  sternum  and  from  paroxysms  of 
severe  pain  in  the  heart ;  that  he  sighs  or  yawns  frequently  ;  that  he 
is  easily  put  out  of  breath  ;  that  his  skin  has  a  yellow,  oily  look ;  that 
he  is  subject  to  syncope,  or  to  seizures  during  which  his  respiration 
seems  to  come  to  a  stand-still;  and  that  he  is  liable  to  vertigo,  to 
attacks  of  transitory  unconsciousness,  or  to  be  stricken  down  with 
repeated  attacks  having  the  character  of  apoplexy,  save  that  they  are 
not  followed  by  paralysis. 

Now,  here  is  certainly  a  group  of  phenomena  dissimilar  to  those 
of  a  dilated  heart.  Let  us  add  that  the  extent  of  the  cardiac  percus- 
sion dulness  remains  unaltered,  except,  in  those  instances  in  which 
hypertrophy  or  dilatation  coexists,  that  dropsies  and  local  congestions 
are  not  prominent  symptoms,  or  indeed  do  not  happen  at  all,  and  the 
dissimilarity  becomes  still  greater.  A  differential  diagnosis  would, 
under  such  circumstances,  be  anything  but  difficult.  But  in  point  of 
fact  the  matter  is  generally  not  so  easily  decided,  and  there  are  several 


DISEASES  OF  THE  HEART.  4]  5 

reasons  why  it  is  not.  One  is,  that  all  the  features  described  are 
rarely  combined  in  the  same  case ;  indeed,  one  of  the  most  marked, 
the  Cheyne-Stokes  breathing,  is  uncommon  rather  than  common,  and 
occasionally  occurs  in  other  cardiac  maladies.  The  second  is,  because 
non-fatty  softening,  the  result  of  a  granular  infiltration,  as  met  with, 
for  instance,  in  fevers,  may  present  much  the  same  vital  and  physical 
manifestations.  The  third  is,  because  a  fatty  heart  has  a  tendency  to 
become  dilated,  and  the  symptoms  and  signs  of  the  former  disease 
are  then  merged  into  the  symptoms  and  signs  of  the  latter.  With 
the  organ  in  such  a  condition,  the  practical  value  of  a  differential 
diagnosis  is,  however,  not  great.  Decided  dropsy  would  indicate  that 
dilatation  had  happened. 

The  remarks  about  fatty  heart  apply  particularly  to  that  variety  in 
which  the  muscular  structure  in  middle-aged  or  elderly  persons  has 
slowly  undergone  decay,  and  which  is  especially  seen  in  men  of  seden- 
tary habits,  in  tipplers,  in  the  gouty,  or  in  diabetics  ;  disease  of  the 
coronary  arteries  often  coexists.  But  we  meet  with  fatty  heart,  al- 
though far  less  frequently,  in  young  persons,  and  in  a  more  acute 
form ;  and  we  encounter  it  in  chlorosis,  in  pernicious  ansemia,  after 
repeated  hemorrhages,  and  after  phosphorus  poisoning.  Poisonous 
doses  of  acids,  such  as  nitric,  sulphuric,  oxalic,  are  said  by  von  Dusch 
also  to  give  rise  to  the  cardiac  change. 

Persons  who  have  fatty  hearts  are  subject  to  attacks  of  faintness, 
preceded  or  attended  with  sensations  of  great  coldness^  or  a  chill. 
Sometimes  these  attacks  happen  daily,  or  every  few  days,  and  in  such 
a  manner  as  to  give  rise  to  the  impression  that  they  are  due  to 
malaria.  A  number  of  instances  of  the  kind  have  come  under  my 
observation,  and  I  have  met  with  them  particularly  at  the  end  of 
fevers  or  other  debilitating  diseases  happening  in  those  affected  with 
feeble  hearts.  The  seizures,  though  bearing  a  resemblance  to  inter- 
mittent fever,  are  unlike  it  in  being  associated  with  signs  of  great 
weakness  of  the  circulation  or  heart  failure,  sometimes  joined  to  a 
sense  of  impending  dissolution ;  in  their  irregular  accession ;  and  in 
their  not  being  followed  by  fever.  In  doubtful  cases  the  thermometer 
by  showing  the  absence  of  the  great  rise  of  temperature  of  the  mala- 
rial disorder,  will  materially  assist  us  in  the  diagnosis. 

Heart  starvation^  to  which  Fothergill^  has  called  attention,  has,  in 
the  feeble  circulation,  the  cold  extremities,  the  tendency  to  vertigo, 
and  the  pseudo-apoplectic  attacks,  symptoms  common  with  those  of 
fatty  heart.     But  the  malady  is  not   associated  with    disease  of  the 

1  Edinburgh  Medical  Journal,  May,  1881. 


416  MEDICAL  DIAGNOSIS. 

arteries,  and  is  often  an  attendant   upon  general  ill  nutrition,  and 
worry,  and  long  hours  of  work  and  short  hours  of  sleep. 

A  fatty  heart  sometimes  ruptures.  The  symptoms  that  are  mostly 
noticed  are  these :  the  patient  is  suddenly  attacked  with  intolerable 
anguish  in  the  heart ;  he  presses  his  hand  to  it,  then  faints,  and  soon 
expires.  Or  else  he  lives  for  a  short  time,  suffering  from  faintness, 
cramps,  and  difficulty  of  breathing,  and  with  death  plainly  written  on 
his  face. 

Chronic  myocarditis  with  fibroid  changes  in  the  heart  wahs  cannot 
be  distinguished  with  any  certainty  from  fatty  heart.  Extensive  arte- 
rial degeneration,  accentuation  of  the  second  aortic  sound,  signs  of 
hypertrophy,  attacks  of  palpitation  and  constant  pain  in  the  region  of 
the  heart  would  be  in  favor  of  cardiac  fibrosis.  But  not  one  of  these 
symptoms  is  convincing  proof. 

Where  there  is  fatty  accumulation  on  the  heart,  without  fatty  change 
of  its  fibres, — a  condition  we  sometimes  find  in  fat  persons  whose 
internal  viscera  are  loaded  with  fat, — the  manifestations  are  those 
of  a  feeble  heart,  and  different  from  fatty  degeneration  only  in 
degree.  The  first  sound  of  the  heart  is  weak  and  toneless :  the 
pulse  is  feeble,  but,  as  Walshe  tells  us,  regular.  The  percussion 
dulness  in  the  cardiac  region  is  somewhat  increased.'  A  sensation 
of  oppression  over  the  region  of  the  heart,  or  even  actual  pain,  is 
complained  of.  There  is  shortness  of  breath  on  taking  exercise  and 
sometimes  pretibial  oedema.  Fatty  infiltration  may  be  followed  by 
fatty  degeneration. 

Of  atrophy  of  the  heart  we  know  very  little.  All  we  know  is  that 
at  times  in  certain  wasting  diseases,  such  as  tubercular  phthisis,  can- 
cer, and  suppurating  bone  affections,  the  heart  atrophies  ;  it  may  also 
do  so  when  the  pericardium  is  tightly  adherent ;  and  cardiac  atrophy 
is  said  to  happen  occasionally  after  pregnancy  and  chlorosis.  It  has 
not  a  single  symptom  nor  a  single  sign  by  which  it  can  be  recognized 
with  certainty.  Diminished  percussion  dulness,  clear  sounds,  and 
feeble  impulse  might  enlighten  us  ;  but,  even  in  cases  where  we  have 
not  been  misled  by  emphysema  of  the  lungs,  or  there  is  no  coexisting 
fatty  change,  they  are  too  uncertain  to  be  made  a  basis  for  diagnosis, 
or  attending  lung  conditions  throw  doubt  on  several  of  them.  There 
is  great  tendency  to  palpitation,  and  the  pulse,  Hayden  tells  us,  is 
quick,  all  but  inappreciable,  yet  regular.  The  X-rays  would  furnish 
a  valuable  means  of  diagnosis. 

Pericardial  Effusion. — Pericardial  effusion  also  presents  the 
signs  of  a  weak  heart  with  increased  dulness  on  percussion  in  the 
cardiac  region,  and  is  liable  to  be  mistaken  for  dilatation  of  the  organ. 


DISEASES  OF  THE  HEART.  417 

But  though  there  are  points  of  resemblance  to  a  dilated  heart,  there 
are  points  of  contrast,  as  the  subjoined  table  shows  : 

Dilatation  of  the  Heart.  Chronic  Pericarditis  with  Effusion. 

Percussion  dulness  increased  in  extent,     Percussion  dulness  increased,  but  often 

but  square  in  outline.  of  pyramidal  shape. 

Impulse  in  epigastrium.  Impulse  in  third  or  fourth  left  interspace, 

apex  tilted  upward. 
Heart-sounds    clear   and    sharp ;    some-     Heart-sounds  feeble   and  distant-sound- 
times,  however,  feeble.  ing  at  the  apex,  but  distinct  near  the 

upper  part  of  the  sternum. 
No  friction  sound.  Often  friction  sound  still  heard  at  base. 

Dropsy ;    signs    of    venous    stagnation ;     Neither   dropsy  nor   venous    stagnation, 
severe  cough;  and  dyspnoea.  Cough    and    dyspnoea    are    not    such 

prominent  symptoms. 
The  history  of  the  disease  shows  it  to     The    history   frequently   points    to    the 
be  gradually  developed.  acute  attack. 

Diseases  of  the  Heart  exhibiting  more  or  less  of  the  Signs 
and  Symptoms  of  Enlargement  of  the  Organ,  and  accom- 
panied by  Endocardial  Murmurs. 

Valvular  Affections. — These,  when  not  due  to  congenital  mal- 
formations, are  most  commonly  the  result  of  rheumatic  endocarditis, 
of  slowly  progressing  sclerotic  changes,  or  of  heart-strain,  A  certain 
number  of  cases  have  their  origin  in  some  of  the  fevers,  as  in  scarlet 
fever,  and  in  septic  conditions  and  blood-changes,  as  in  malignant 
endocarditis.  The  different  valves  are  not  affected  by  these  causes 
alike.  Rheumatic  endocarditis  is  the  principal  cause  of  disease  of  the 
mitral  valve,  especially  of  mitral  insufficiency ;  but  among  prominent 
causes  of  this  are  also  alterations  in  the  muscular  wall  of  the  ventricle 
or  in  the  tendinous  cords.  Aortic  insufficiency  is  generally  due  to 
slow  sclerotic  changes  in  the  valvulets,  whether  attended  with  atheroma 
or  not,  or  to  subacute  or  chronic  endocarditis  from  heart-strain ; 
it  may  be  also  owing  to  the  sudden  rupture  of  a  valve  previously 
damaged.  Mitral  constriction  is  mostly  brought  about  by  atheroma- 
tous or  calcareous  alteration,  as  is  aortic  constriction  ;  but  in  mitral 
constriction  we  may  have  also  a  history  of  endocarditis  in  early  child- 
hood subsec{uent  to  rheumatism,  an  exanthematous  fever,  or  chorea. 
In  insufficiency  of  the  tricuspid  valve  we  can  trace  usually  the  result 
of  over-distention  of  the  right  heart,  such  as  follows  pulmonary  con- 
gestion caused  by  mitral  disease,  or  of  an  obstructive  disease  of  the 
lung,  such  as  emphysema  or  cirrhosis.  Tricuspid  stenosis,  and  the 
other  very  rare  valvular  affections  of  the  heart, — those  of  the  pul- 
monary artery, — are  commonly  congenital. 


418  MEDICAL  DIAGNOSIS. 

To  find  the  sounds  of  the  heart  clearly  and  well  defined,  is  to 
know  that  no  disease  of  the  valve  exists.  When  the  valvular  appa- 
ratus is  disordered,  the  mischief  betrays  itself,  for'  the  most  part,  by  a 
murmur.  If,  therefore,  a  murmur  of  any  permanence  be  met  with  in 
the  heart,  especially  if  it  be  associated  with  the  signs  of  either  hyper- 
trophy or  dilatation,  the  inference  that  valvular  disease  exists  will  in 
the  vast  majority  of  cases  be  correct. 

Yet  it  will  not  be  so  always ;  for  there  are  other  morbid  states 
besides  valvular  affections  which  engender  a  murmur,  which  may  be 
even  accompanied  by  all  the  manifestations  of  enlargement  of  the 
heart.  Malformations,  such  as  communications  between  the  auricles 
or  between  the  ventricles,  or  between  the  great  vessels  near  their 
origin,  or  impoverished  blood,  or  a  misdirected  blood-current,  may 
occasion  a  murmur. 

Now,  with  reference  to  malformations^  their  presence  in  adults,  or 
in  children  that  have  passed  the  days  of  infancy,  is  exceedingly  rare. 
The  most  trustworthy  symptom  they  present  is  that  indicating  the 
admixture  of  arterial  and  of  venous  blood ;  in  other  words,  the 
symptom  of  cyanosis,  the  bluish  discoloration  of  the  skin.  In  addi- 
tion, we  may  perceive  clubbing  of  the  nails,  a  tendency  to  hemorrhage, 
breathlessness,  or  dyspnoea,  cough,  and  irregular  action  of  the  heart, 
and  a  blowing  sound  in  the  cardiac  region  ;  hypertrophy  of  the  heart, 
especially  of  the  right  heart,  is  also  very  generally  present.  Still,  the 
recognition  of  these  malformations  is  always  more  or  less  a  matter 
of  conjecture.  With  the  aid  of  more  such  researches  as  those  of 
Moreton  Stille,^  of  Peacock,^  of  Hochsinger,*  and  of  Theraum,'^  we  shall 
perhaps  be  able  ultimately  to  discern  them  with  certainty  during  life. 

As  a  few  points  of  assistance,  it  may  be  mentioned  that  commu- 
nication of  the  ventricles  through  the  septum  gives  rise  to  a  systolic 
murmur  at  or  near  the  base  of  the  heart  not  propagated  into  the 
arteries,  but  according  to  Roger  and  to  Sansom,  also  heard  between 
the  shoulders  ;  that  the  passage  of  blood  through  an  open  foramen 
ovale  very  rarely  engenders  any  sound,  though  presenting  marked 
cyanosis  ;  and  that,  whether  coexisting  with  these  lesions  or  not,  the 
majority  of  instances  of  cardiac  malformation,  after  the  age  of  twelve, 
present  signs  of  obstruction  at  the  orifice  of  the  pulmonary  artery. 
In  this  instance  either  a  systolic  or  a  diastolic  murmur  may  be  there 
perceived  ;  in  the  first  case  the  second  sound  of  the  heart  is  weak  or 

^  American  Journal  of  the  Medical  Sciences,  July,  1844. 
^  Treatise  on  Malformations  of  the  Heart. 
^  Die  Auscultation  des  Kindlichen  Herzens,  Wien,  1890. 
*  Etudes  sur  les  Affections  congenital  du  Coeur,  Paris,  1895. 


DISEASES  OF  THE  HEAKT.  419 

wanting  in  the  second  interspace  on  the  left  side.  Mitral  disease  of 
congenital  origin  is  very  rare.  Thrill  over  the  praecordial  region  is 
seldom  met  with,  except  when  congenital  defect  in  the  septum  exists. 
Loud,  vibratory  systolic  murmurs  heard  most  distinctly  over  the 
upper  third  of  the  sternum  without  attending  hypertrophy  of  the  left 
ventricle  point  to  persistence  of  the  ductus  Botalli.  A  curious  result 
of  cardiac  malformation  has  been  observed, — abscess  of  the  brain 
without  appreciable  cause, ^ 

The  resemblance  borne  by  cases  of  functional  disturbance  of  the 
heart,  associated  with  impoverished  blood,  to  valvular  affections,  has 
already  engaged  our  attention.  The  age  ;  the  anaemic  look ;  the  seat 
of  the  murmur  at  the  base  of  the  heart,  as  well  as  at  the  apex,  and  its 
soft  character ;  the  venous  hum  ;  the  fact  that  the  cardiac  murmur 
does  not  entirely  supersede  the  first  sound  and  is  followed  by  a  dis- 
tinct second  sound ;  that  the  apex  beat  is  not  displaced,  and  that  the 
murmur  is  not  heard  at  the  back,  are  all  points  upon  which  some 
stress  may  be  laid ;  yet  not  so  much  as  upon  the  absence  of  the  phe- 
nomena of  an  enlarged  heart.  But  if  the  question  be  asked.  Are  the 
latter  absolute  demonstrations  of  the  existence  of  an  affection  of  the 
valves?  cannot  an  hypertrophied  or  a  dilated  heart,  with  sound 
valves,  be  combined  with  a  condition  of  blood  capable  of  producing  a 
murmur? — we  are  forced  to  answer  that  such  is  possible.  Under 
these  circumstances,  the  tact  of  the  "physician  may  help  him  to  a 
well-judged  decision ;  but  the  only  proof  of  a  well-judged  decision  is 
afforded  by  time,  or  by  the  result  of  treatment  that  restores  the  blood 
to  its  normal  state. 

A  murmur  caused,  in  violent  excitement  of  the  heart,  by  mis- 
direction of  the  current,  due  chiefly  to  temporary  interference  with  the 
closure  of  the  valves,  or  perhaps  owing  to  altered  tension  of  the 
valves, — causes  the  exact  working  of  which  I  have  elsewhere  in- 
quired into,^ — may  become  a  troublesome  source  of  error  in  diag- 
nosis, especially  when  heard  over  a  heart  in  a  state  of  dilated  hyper- 
trophy or  of  dilatation.  Fortunately,  a  blowing  sound  of  this  origin 
and  in  this  combination  is  comparatively  rare,  and  we  are  enabled  to 
discriminate  it  from  an  organic  valvular  murmur  by  its  not  being  per- 
sistent. It  is  much  more  likely  to  be  heard  at  the  apex,  or  rather, 
according  to  my  own  observations,  somewhat  above  the  apex,  than  is 
a  murmur  owiug  to  changes  in  the  blood ;  and  it  differs  from  the 
systolic   blowing   sound   of  mitral   disease   partly  by  the   peculiarity 

^  Ballet,  Archives  Generales  de  Medecine,  June,  1880. 

^  On  Functional  Valvular  Disorders,  Amer.  Journ.  Med.  Sci.,  July,  1869. 


420  MEDICAL  DIAGNOSIS. 

of  seat  just  mentioned,  partly  by  its  non-diffusion,  its  usual  absence 
at  the  back  of  the  chest,  the  want  of  harshness  in  the  inconstant 
murmur,  and  the  low  pitch.  Murmurs  of  this  kind  are  also  caused  by 
obstructive  diseases  of  the  lungs,  without  disease  of  the  heart  being 
present.  They  may  be  brought  out,  as  John  K.  Mitchell  has  shown, 
by  suddenly  closing  the  hand  tightly.^ 

At  tunes  a  murmur  is  heard  which  is  not  dependent  on  a  cardiac 
affection,  but  on  lung  changes.  We  fmd,  for  instance,  in  consolida- 
tion of  the  left  apex,  especially  if  the  lung  be  also  contracted,  a 
murmur,  almost  invariably  systolic,  over  the  site  of  the  pulmonary 
artery  ;  or  we  may  encounter  over  large  cavities  with  thin  walls,  situ- 
ated in  the  neighborhood  of  the  heart,  a  systolic,  cardio-pulmonary 
murmur,  caused,  most  likely,  by  the  agitation  of  the  air  in  the  cavity, 
the  heart  being  quite  sound. 

These,  then,  are  the  causes  which  impair  the  value  of  the  cardiac 
blowing  sound  as  a  sign  of  a  valvular  lesion.  Yet  they  do  not  happen 
often  enough  to  prevent  us  from  regarding  a  persistent  murmur  as 
eminently  indicative  of  an  organic  affection  of  the  valves. 

Let  us  suppose  that  we  are  convinced  that  the  murmur  is  due  to 
a  structural  lesion.  Can  we  say  what  its  precise  nature  is  ?  Can  we 
accurately  foretell  that  the  valve  is  merely  roughened,  or  that  it  has 
undergone  calcareous  transformation,  or  that  it  has  been  bound 
down,  or  that  it  is  lacerated, '  or  that  vegetations  spring  from  it,  or 
that  its  muscular  attachments  are  sound  or  unsound  ?  No,  assuredly 
not.  The  most  we  can  do  is  to  judge  whether  the  orifices  through 
which  the  current  flows  are  narrowed,  or  whether,  by  the  valves  not 
closing,  they  permit  of  regurgitation ;  and  to  distinguish  even  this  we 
have  to  take  into  account  more  the  time  of  the  occurrence  of  the 
sound  than  its  particular  character  or  pitch.  Indeed,  all  distinctions 
based  entirely  on  either  of  these  are  not  borne  out  by  clinical  experi- 
ence. Valves  incompetent  to  close  the  openings  at  which  they  are 
seated  may  permit  a  murmur  to  be  generated  of  any  character  and  of 
any  pitch.  It  is  true  that  a  harsh  murmur,  like  that  of  a  saw  or  of  a 
rasp,  is  for  the  most  part  occasioned  by  a  contracted  orifice  with  rigid 
valves.  In  obstruction  at  the  mitral  and  tricuspid  orifice,  the  murmur 
is  mostly  rough  or  rumbling.  Broadbent  ^  maintains  that  a  loud  and 
long  murmur  is  significant  of  less  structural  damage  and  functional 
imperfection  than  a  short  and  weak  murmur. 

A  cardiac  sound  which  is  rare,  but  which,  when  present,  is  gen- 

^  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1892. 
2  Heart  Disease,  1898. 


DISEASES  OF  THE  HEAET.  421 

erally  associated  with  a  narrowed  orifice,  is  a  distinct  musical  tone 
heard  at  the  mitral  or  aortic  valves.  It  resembles  the  cooing  of  a 
pigeon ;  or  the  auscultator  listens  and  listens  again,  and  directs  the 
patient  again  and  again  to  suspend  his  breathing,  before  he  becomes 
convinced  that  the  sound  is  not  a  sibilant  rale  in  the  lung.  It  is  some- 
times perceived  merely  at  the  beginning,  or  the  end,  or  only  in  the 
middle  of  an  ordinary  murmur,  and  disappears  and  reappears. 
Where  this  rare  sound  is  met  with,  the  valves  are  usually  rigid  and 
unyielding.  Yet  this  is  not  always  the  case.  Sometimes  the  musical 
note  is  produced  by  the  vDDrations  of  clots  which  impede  the  rush  of 
blood  through  the  apertures  of  the  heart,  or  by  the  loose  edge  of  a 
valve  flapping  to  and  fro  in  the  current.  Occasionally,  too,  we  hit 
upon  it  in  chlorosis  ;  but  only  very  occasionally,  and  never  unless  it 
be  then  equally  or  more  marked  in  the  arterial  system.  We  have 
the  authority  of  Stokes  for  the  observation  that  it  may  be  suddenly 
developed  and  precede  the  signs  of  structural  alteration  of  the  heart. 
Schroetter  maintains  that  the  musical  murmur  is  due  to  the  vibration 
of  a  fine  fibrous  band  stretched  across  the  ventricle  or  a  valvular 
orifice.^ 

It  has  been  already  stated  that  we  judge  best  of  the  condition  of 
the  orifices  and  of  the  valves  by  ascertaining  the  time  at  which  the 
murmur  occurs.  But  it  is  also  necessary  to  recall  the  state  of  the 
orifices  during  the  movements  of  the  healthy  heart.  During  the  con- 
traction of  the  ventricles,  the  valves  at  the  auriculo-ventricular  open- 
ings are  closed,  to  prevent  regurgitation  into  the  auricles,  and  the 
valves  of  the  aorta  and  pulmonary  artery  are  open.  During  the  dila- 
tation of  the  heart  the  reverse  takes  place :  the  valves  at  the  origin  of 
the  great  arteries  are  shut,  and  the  valves  which  act  as  gates  to  the 
auriculo-ventricular  apertures  are  swung  back,  to  allow  the  stream  to 
flow  into  the  ventricles. 

If  then  a  murmur  occur  with  the  contraction  of  the  heart  and  the 
first  sound,  it  is  owing  to  the  blood  either  regurgitating  from  the  ven- 
tricles into  the  auricles,  or  meeting  with  difficulty  in  passing  into  the 
aorta  or  pulmonary  artery  ;  if  it  occur  after  the  contraction  of  the  heart, 
and  correspond  to  the  second  sound,  it  is  due  to  the  blood  passing 
through  a  narrowed  mitral  or  tricuspid  orifice,  or  streaming  back  into, 
the  ventricles  through  incompetent  aortic  or  pulmonary  valves.  But 
can  we  distinguish  at  which  valve  the  mischief  lies  ?  Generally  we 
can.  By  attending  to  the  site  of  greatest  intensity  of  the  murmur,  we 
become  aware  of  the  seat  of  its  production,  provided  it  be  borne  in 

^  Wien.  Med.  Blatter,  No.  1,  1883. 


422 


MEDICAL  DIAGNOSIS. 


mind  what  are  the  points  at  which  to  Hsten  to  the  different  valves. 
It  is,  however,  also  necessary  to  recollect  that,  as  the  whole  heart  is 
somewhat  lowered,  these  points  are  rather  below  what  they  are  in  a 
natural  state  of  things. 

Now,  we  cannot  always  say  whether  more  than  one  valve  is  af- 
fected. A  murmur  in  the  heart,  no  matter  where  it  is  generated,  is 
usually  transmitted  all  over  the  organ.     If  it  mask  the  natural  sounds 

Fig.  48. 


Narrowing  of  the  aortic  orifice  by  vegetations  springing  from  the  valves,  the  structure  of  which 
was,  indeed,  to  a  great  extent,  destroyed.  The  engraving  illustrates  also  the  physical  signs  of 
aortic  constriction. 

at  other  valves,  it  is  very  difficult,  nay,  it  is  often  impossible,  to  tell 
positively  how  many  of  the  valves  are  injured,  unless  several  spots 
be  detected  at  which  the  murmur  is  intense,  yet  not  alike  in  character. 
The  valves  that  most  frequently  show  coexisting  disease  are  the  mitral 
and  the  aortic,  particularly  insufficiency  of  both,  or  aortic  narrowing 
with  mitral  insufficiency.  Diseases  of  mitral  and  tricuspid  are  also 
found  to  coexist,  whether  the  lesion  be  regurgitation  or  narrowing. 


DISEASES  OF  THE  HEART. 


423 


In  all  instances  the  precise  character  of  the  murmur  at  the  different 
sites  of  the  heart  is  of  the  greatest  significance. 

Thus  the  murmur  is  the  most  conspicuous  and  most  constant  sign  of 
a  valvular  lesion.  The  other  signs  and  symptoms  vary  greatly  in  indi- 
vidual cases.  Where  the  valves  are  but  slightly  affected,  let  us  say 
slightly  roughened,  as  they  sometimes  are  after  an  attack  of  rheumatic 
endocarditis,  the  heart  does  not  undergo  any  decided  change  in  size ; 


Fig.  49. 


Insufficient  mitral  valves  permitting  regurgitation  of  the  blood.    The  position  and  time  of  occur- 
rence of  the  most  significant  sign  of  the  affection  are  indicated  in  the  engraving. 


the  circulation  is  carried  on  regularly,  and,  in  spite  of  the  abnormal 
sound  in  the  heart,  the  patient's  health  remains  unimpaired,  or  it  is 
only  occasionally  that  he  suffers  from  palpitations.  An  alteration  of 
the  valves  of  the  heart  of  any  extent  produces,  however,  an  alteration 
either  in  the  capacity  of  its  cavities  or  in  the  thickness  of  its  walls, 
and  the  symptoms  of  dilatation  or  hypertrophy  make  their  appearance 
along  with  the  physical  signs  of  extended  percussion  dulness  and 
feeble  or  heaving  impulse.  Ordinarily  it  is  the  latter  we  meet  with, 
because  the  valves  of  the  left  side  are  so  very  much  more  frequently 
diseased,  and  their  derangements  lead  to  hypertrophy  rather  than  to 
dilatation.  Affections  of  the  tricuspid  valves  are  ustially  connected 
with  dilatation  of  the  organ ;  hence  dropsy,  venous  turgescence  and 
albuminous  urine  are  in  them  more  especially  observed ;  and  Blakis- 


424  MEDICAL  DIAGNOSIS. 

ton  has  taught  us  their  frequent  association  with  engorgement  of  the 
vessels  of  the  brain,  and  how  this  becomes  the  predisposing  cause  of 
cerebral  apoiDlexy  when  in  connection  with  cardiac  disease.  We  also 
find  in  them,  or  rather  in  tricuspid  insufficiency,  what  Mahot  has  more 
particularly  called  attention  to, — a  pulsation  of  the  liver  correspond- 
ing to  each  systole  of  the  heart,  perceived  by  gently  depressing  the 
abdominal  parietes  with  the  hand  on  the  epigastrium.  In  combined 
tricuspid  and  mitral  narrowing  we  may  have  the  signs  of  pulmonary- 
artery  regurgitation.^  In  high  degrees  of  aortic  insufficiency,  a  sys- 
tolic apex  murmur,  as  pointed  out  by  Flint,  is  very  often  produced  by 
dilatation  of  the  mitral  orifice.  The  murmur  differs  from  that  over 
the  damaged  aortic  valves,  and  may  be  presystolic  in  time.  In  coex- 
isting aortic  and  mitral  insufficiency  the  compensatory  hypertrophy  is 
arrested.  In  some  cases  of  mitral  regurgitation  the  mitral  murmur 
occupies  only  the  middle  or  the  latter  part  of  the  systole.^  In  in- 
stances of  disease  of  three  valves,  as  in  the  case  reported  by  Shat- 
tuck,^  douJDle  murmurs  of  dissimilar  kind  may  be  heard  over  the  area 
of  the  different  orifices. 

All  valvular  lesions  may  be  combined  with  pain  in  the  prgecordia, 
palpitations,  restlessness,  and  disturbed  dreams.  And  according  as 
the  deranged  circulation  through  the  heart  interferes  with  the  circu- 
lation in  other  parts,  special  symptoms  show  themselves  prominently. 
Thus,  we  find  those  who  labor  under  a  mitral  disease  suffering  most 
from  cough,  from  dyspnoea,  and  from  attacks  of  cardiac  asthma,  since 
it  is  the  lung  which  has  to  bear  the  brunt  of  the  embarrassed  flow  of 
the  blood.  If  we  examine  this  organ  closely,  the  physical  sounds  afford 
direct  proof  of  its  disordered  condition.  Here  and  there  are  heard 
plentiful  moist  sounds  from  fluid  which  has  leaked  into  air-tubes  ; 
here  and  there  the  respiratory  murmur  is  roughened,  and  percussion 
shows  impaired  clearness.  This  loss  of  the  natural  resonance  is  at 
times  very  manifest  at  the  upper  part  of  the  lung,  and  I  have  known 
it  to  give  rise  to  the  suspicion  of  tubercular  deposit  in  cases  in  which 
the  autopsy  proved  the  pulmonary  tissue  to  be  healthy,  though  in  a 
state  of  extreme  congestion.  Respiratory  percussion  renders  the 
sound  again  clear.  Mitral  insufficiency  generally  leads  to  hypertrophy 
of  the  heart ;  mitral  stenosis  becomes  associated  mth  dilatation,  or 
there  is  only  hypertrophy  of  the  right  ventricle. 

When  the  aortic  valves  permit  of  regurgitation,  this  gives  rise  to 

1  Dyce  Duckworth,  Clin.  Soc.  Transact.,  Jan.  1888. 

2  Crozer  Griffith,  Amer.  Journ.  Med.  Sci.,  Sept.  1892. 
^  Boston  Medical  and  Surgical  Journal,  1891. 


DISEASES  OF  THE  HEART. 


425 


effects  which  are  perceptible  along  the  track  of  the  arteries.  These 
all  look  superficial,  and  beat  with  apparent  violence,  from  the  force 
with  which  the  thickened  left  ventricle  is  driving  the  blood  through 
the  tubes.  The  pulsation  of  the  vessels  may  be  even  seen  in  the 
retinal  vessels  with  the  aid  of  the  ophthalmoscope.  Yet,  when  the 
finger  is  applied  to  the  artery  at  the  wrist,  the  strength  of  the  beat  is 
not  so  great  as  expected.  A  short,  abrupt,  jerking  impulse  is  indeed 
communicated  to  the  finger ;  but  then  the  artery  immediately  recedes, 
proving  that  it  was  only  imperfectly  filled.  This  pulse  is  the  only  one 
which  gives  us  any  real  information  as  to  the  state  of  the  orifices  of 
the  heart.  In  general  terms,  it  may  be  stated  that  the  pulse  is  small 
and  rather  tense  when  the  openings  are  narrowed.  Still,  no  stress 
can  be  laid  on  this  in  a  diagnostic  point  of  view.  The  want  of  cor- 
respondence between  the  strength  of  the  pulse  and  the  force  with 
which  the  heart  is  acting  is  often  amazing.  If  the  second  sound  can 
be  heard  in  the  neck  over  the  carotid  artery  it  shows  that  the  regurgi- 
tation is  not  large  in  amount.^  In  marked  regurgitation  a  capillary 
pulse,  as  seen,  for  instance  in  the  finger-nails,  is  common. 

More  information  than  by  merely  feeling  the  pulse  can  be  obtained 
by  studying  it  with  the  sphygmograph.  But  even  with  this,  as  thus 
far  developed,  we  gather  in  valvular  diseases  rather  corroborative  evi- 
dence than  knowledge  which  is  not  attainable  by  other  means  of  diag- 

■     Fig.  50. 


Sphygmogratn  taken  from  a  patient  with  aortic  insufficiency.    The  line  of  ascent  does  not  termi- 
nate in  as  sharp  a  ix)int,  nor  is  tlie  descent  as  sudden,  as  we  sometimes  find  it. 

Fig.  51. 


Sphygmogram  taken  from  a  patient  presenting  tlic  signs  of  niitral  regurgitation. 

nosis.  Perhaps  with  further  research  the  instrument  may  be  made 
available  to  inform  us  with  certainty  of  the  degree  of  the  valvular 
imperfection  ;  and  this  would  be  a  great  step  in  advance.  As  regards 
the  most  distinctive  graphical  signs,  we  obtain  them  in  aortic  regurgi- 
tation,— a  vertical  line  of  ascent  of  great  amplitude,  a  pointed  sum- 


^  Broadbent,  Diseases  of  the  Heart,  1898. 


426 


MEDICAL  DIAGNOSIS. 


mit,  and  a  sudden  descent,  with  comparatively  little  dicrotism.  If 
there  be  also  marked  aortic  obstruction,  the  line  of  ascent  is  oblique, 
or  rather  the  first  part  is  vertical,  and  follomng  the  sharp  point  is  a 
gradual  curve-like  rise ;  if  senile  changes  in  the  artery  complicate  the 
aortic  insufficiency,  the  sharp-pointed  process  terminating  the  line  of 
ascent  passes  into  a  more  or  less  horizontal  plateau.  In  instances  of 
decided  uncomplicated  aortic  obstruction  there  are  sloping  up-strokes 
and  down-strokes. 

In  mitral  regurgitation  the  pulse  tracing  is  usually  very  irregular, 
such  as  is  seen  at  times  in  aneurism ;  the  line  of  ascent  is  short  and 
unequal,  and  the  line  of  descent  is  disposed  to  be  oblique  and  to 
present  marked  dicrotism.  In  mitral  constriction  there  is  also, 
usually,  irregularity  ;  it  is  asserted  by  Mahomed  ^  that  the  up-stroke  is 
vertical,  and  that  there  is,  especially  after  giving  digitalis,  a  secondary 
and  very  characteristic  contraction  of  the  ventricle  manifest  in  the 
dicrotic  wave.     Sansom  ^  agrees  in  the  main  with  this  observation. 

But,  instead  of  entering  into  a  detailed  description  of  the  pulse, 
however  studied,  or  of  any  separate  symptoms  of  valvular  disease, 
let  us  group  them  together  mth  the  physical  signs,  according  to  the 
combination  in  which  we  are  wont  to  meet  them  : 


Table  of  Valvular  Diseases. 


Seat  of  Muemue. 

Seat  of 

EASE, 

Dis- 

Chaeactee  of 
Disease. 

Murmur   most   in- 

Mitral orifice. 

With   impulse, 

tense  at  or  near 

means     insufS.- 

apex  of  heart. 

ciency  of  valves, 
permitting  of  re- 
gurgitation; after 
impulse  and  run- 
ning into  or  cor- 
responding to  the 
second  sound,  or, 
more  accurately 
speaking,  gener- 
ally preceding 
the  first  soimd, 
presystolic, 
means  narrowing 
of  the  orifice. 

COEEELATIVE  PHYSICAL  SIGNS  AND 
SYJIPT05IS. 

In  mitral  disease  the  heart  very  com- 
monly undergoes  dilated  hypertrophy, 
especially  the  right  ventricle.  'When 
there  is  also  hj-pertrophy  of  the  left 
ventricle,  it  is  not  simply  mitral  nar- 
rowing. The  second  sound  of  the  pul- 
monary artery,  heard  in  the  second  left 
interspace,  is  sharp,  accentuated.  The 
cardiac  murmur  is  often  distinctly  per- 
ceived posteriorly  on  the  left  side,  near 
the  angle  of  the  scapula.  Dyspncea  and 
dropsy  are  prominent  sjTnptoms,  esi)e- 
cially  dyspncea.  Cough  is  not  unusual, 
and  the  pulse  is  not  infrequently  found 
to  be  feeble  and  irregular.  In  some 
forms  of  mitral  narrowing,  where  the 
curtains  are  not  too  rigid,  the  murmur 
is  always  rough.  Tliis  is  the  case 
usually  ^vitll  the  presystolic  murmur, 
which  is  pre-eminently  regarded  as  the 
sign  of  mitral  constriction.  But  in  this 
affection  all  murmur  may  be  absent, 
and  a  roughening  of  the  first  sound 
and  doubling  of   the  second  be  the 


Medical  Times  and  Gazette,  May,  1872. 
Diagnosis  of  Diseases  of  the  Heart,  1892. 


DISEASES  OF  THE  HEART. 


427 


Table  of  Valvular  Diseases.  —  Contthued. 


Seat  of  Murmur. 


Murmur  most  in- 
tense at  or  near 
the  middle  of 
the  sternum,  or 
heard -with  equal 
distinctness  close 
to  the  sternum  in 
the  second  inter- 
space on  the  right 
side,  and  thence 
propagated  into 
the  arterial  sys- 
tem. 


Murmur  most  in- 
tense at  or  very 
near  to  the  ensi- 
form  cartilage, 
and  over  the 
lower  part  of  the 
right  ventricle. 


Seat  of  Dis-         Character  of  Correlative  Physical  Signs  and 

EASE.  Disease.  Symptoms. 

signs ;  or  there  may  be  at  the  apex  a 
presystolic  murmur  and  the  second 
sound  be  lost.    In  mitral  narrowing  a 
thrill  in  the  cardiac  region,  presys- 
tolic or  diastolic,  can  be  often  felt.  Mi- 
tral narrowing  is  frequently  associated 
■with  contracted  kidney. 
Aortic  orifice.       With   impulse.    Hypertrophy  of  left  ventricle,  often  to 
means  narrowing,       a  very  great  degree,  the  compensation 
or     obstruction;       being  very  decided.    All  the  cardiac 
with       diastole,       sounds  may  be  normal,  except  at  the 
and    taking    the       aortic  valve,  although  they  are  ob- 
place  of  the  sec-       scured  by  the  murmur.     This  is  dis- 
ond  sound,  or  oc-       tinct  in  the  carotids,  and  is.sometimes 
ciuring   in   both       as  well  heard  at  the  ensiform  cartilage 
sounds,  the  first       as  over  the  sternum  and  on  a  line  with 
murmur      short,       the  third  intercostal  space,  or  in  the 
means   regurgita-       third  or  fourth  interspace  near  the  left 
Hon.  '  edge  of  the  sternum.  When  the  orifice 

is  constricted,  a  purring  thrill  is  fre- 
quently observed  to  attend  the  harsh 
or  musical  systolic  miu-mur.  The 
symptoms  in  aortic  valve  disease  are 
often  remarkably  latent.  There  is 
very  commonly  neither  dropsy  nor 
dyspnoea.  The  pulse  in  regurgitation 
is  abrupt  and  receding,  and  all  the 
superficial  arteries  and  the  capillaries 
pulsate.  It  is  not  unusual  to  find  a 
double  aortic  blowing  sound  attending 
aortic  regurgitation,  probably  from 
slight  coexisting  obstruction  of  the  ori- 
fice, though  this  is  not  always  found  ; 
a  double  murmur  is  also  heard  in  the 
carotids  and  femorals.  A  mitral  apex 
murmur  may  be  also  noticeable. 
Tricuspid  ori-  With  impulse,  re-  Tricuspid  regurgitation  exists  usually  in 
fice.  gurgitation;  with       combination  with   dilatation  of   the 

diastole,  and  tak-       right  ventricle,  and  therefore  with  the 
ing  therefore  the       symptoms  of  this  condition ;  with  ve- 
place  of  the  sec-       nous  congestions,  with  dropsies,  with 
ond    sound,    or,       difiiculty  in  breathing.   On  account  of 
more    generally,       the  open  state  of  the  orifice,  the  cer\'i- 
preceding  the       cal  veins  may  pulsate  during  the  move- 
first,  narrowing.  ments  of  the  heart ;  and  in  all  cases 
they  are  distended.    The  pulsatile  mo- 
tion in  the  neck  becomes  especially 
visible  when  the  breath  is  held  in  ex- 
piration. The  cardiac  murmur  is  ordi- 
narily soft,  of  low  pitch,  is  not  trans- 
mitted into  the  arteries,  and  is  not 
heard  above  the  level  of  the  tliird  rib. 
In  some  cases  it  is  so  feeble  as  to  be 
with  difficulty  discerned.  In  tricuspid 
narrowing,  a  very  rare  disease,  there 
are   presystolic  murmur   and    thrill, 
cyanosis  of  the  face  and  lips,  great 
dropsy,  and  distention  of  the  jugular 
veins,  with  slight,  or  without,  pulsation. 


428 


MEDICAL   DIAGNOSIS. 


Table  of  Valvular  Diseases. — Continued. 


Seat  of  Murmiie. 

Murmur  most  in- 
tense at  the  third 
left  costal  carti- 
lage near  the 
sternum,  or  even 
somewhat  lower, 
or  In  the  second 
intercostal  space 
to  the  left  of  the 
sternum. 


Seat  of  Dis- 
ease. 
Pulmonary  ori- 
fice. 


Chaeactek  of 
Disease. 
With  impulse,  is 
narrowing ;  tak- 
ing the  place  of 
the  second  sound, 
regurgitation. 


coeeelative  physical  signs  and 
Symptoms. 
We  have  little  knowledge,  derived  from 
clinical  observation,  of  diseases  of  the 
pulmonary  valves,  of  all  the  valves  the 
ones  most  rarely  affected.  Nor  does  a 
murmur  in  the  situation  indicated,  and 
hardly  audible  over  the  left  apex  or 
along  the  sternum,  or  in  the  course  of 
the  great  vessels,  having  therefore  the 
characteristics  of  a  pulmonic  murmur, 
warrant  a  diagnosis  of  disease  of  the 
valves :  for  it  may  be  due  to  anaemia ; 
be  caused  by  deposits  at  the  upper  part 
of  the  left  lung ;  or  be  observed  imme- 
diately after  or  during  the  continuance 
of  hemorrhage  from  the  lungs.  But 
these  remarks  scarcely  hold  good  with 
reference  to  a  diastolic  murmur,  and 
not  at  all  as  regards  a  double  murmur. 
If  this  be  present,  and  attended  with 
thrill  and  with  signs  of  dilated  hyper- 
trophy of  the  right  heart,  we  are  justi- 
fied in  concluding  the  disease  to  be  a 
lesion  of  the  pulmonarj'  valves,  or  at 
the  origin  of  the  artery.  But  especially 
if  cyanosis,  continuous  dyspnoea,  and 
clubbing  of  the  fingers  exist.  The  mur- 
mur is  not  propagated  into  the  carotids. 
But  its  position  may  be  deceptive.  We 
must  bear  in  mind  that  in  rare  instances 
of  mitral  disease,  especially  regurgita- 
tion, the  murmur  is  loudest  at  the  pul- 
monary area,  and  it  may  be  so  in  aortic 
regurgitation.  Pulmonary  narrowing 
is  almost  always  congenital,  and  the 
systoUc  murmur  is  loud  and  harsh. 
Pulmonary  insufficiency  may  be  also 
congenital,  or  be  due  to  malignant 
endocarditis. 


In  this  manner  are  the  symptoms  and  signs  of  valvular  affections 
associated.  But  it  is  not  exactly  the  combination  and  precisely  the 
way  in  which  they  happen  in  every  instance,  for  disorders  of  several 
valves  may  be  conjoined. 

Presuming  that  we  have  been  enabled  to  fix  accurately  the  state 
of  each  aperture,  there  is  a  point  where  all  our  skill  invariably  comes 
to  a  stand-still.  We  cannot  tell  how  long  it  is  possil^le  for  life  to 
continue,  or  under  what  circumstances  death  will  happen.  It  may 
take  place  suddenly  and  most  unexpectedly  in  cases  in  which  the 
amount  of  disease  in  the.  heart  is  not  found  to  be  great ;  and,  on  the 
other  hand,  life,  and  even  a  tolerable  degree  of  health,  may  be  maui- 
tained  with  valves  so  rigid  and  unyieldmg  that  the  point  of  the  knife 
can,  at  the  autopsy,  hardly  be  forced  through  them.  In  mitral  dis- 
ease the  patient  is  liable  to  be  worn  out  by  the  dropsy  and  the  in- 


DISEASES  OF  THE  HEART.  429 

creasing  difficulty  of  breathing ;  and  so,  too,  in  that  still  more  serious 
lesion^ — tricuspid  regurgitation.  In  affections  of  tlie  aortic  valves  the 
patient  suffers  less,  but  he  is  more  liable  to  sudden  death. 

Before  dismissing  these  valvular  affections,  there  are  a  few  other 
matters  which  claim  consideration,  though  the  limits  set  to  this  work 
will  prevent  their  full  discussion.  The  blowing  sound  has  been  in- 
sisted upon  as  the  diagnostic  sign  of  a  valvular  lesion,  and  to  insist 
upon  this  is  to  do  no  more  than  universal  experience  warrants.  But 
there  are  undoubtedly  instances  in  which  no  murmur  reaches  the  ear 
to  show  that  the  valves  are  damaged. 

I  shall  cite  two  examples.  A  man,  thirty-five  years  of  age,  came 
under  my  care,  complaining  of  palpitation  of  the  heart,  of  occasio,Qa| 
attacks  of  bronchitis,  and  of  shortness  of  breath.  His  health  was 
otherwise  good.  A  physical  examination  of  the  chest  showed  the 
action  of  the  heart  to  be  extremely  disturbed :  the  impulse  was  strong, 
and  the  extent  of  dulness  in  the  prsecordial  region  increased.  A 
blowing  sound  was  heard  near  the  apex,  but,  owing  to  the  great 
irregularity  of  the  movements  of  the  heart,  it  was  impossible  to  say 
whether  it  corresponded  in  time  to  the  contraction  or  to  the  relaxa- 
tion of  the  organ.  The  pulse  was  small,  frequent,  and  intermittent. 
The  patient  continued  in  this  state  for  seven  months,  the  beat  of  the 
heart  becoming  more  and  more  tumultuous  ;  but  the  murmur  gradu- 
ally disappeared.  A  peculiar  clacking  sound  took  its  place,  which  was 
most  distinct  near  the  apex,  and  was  faintly  transmitted  to  other  por- 
tions of  the  heart.  It  occurred  with  but  one  sound  of  the  heart, — 
with  which  could  not  be  determined.  For  some  time  before  his  death 
he  had  considerable  cough,  with  a  frothy  expectoration  and  great 
difficulty  in  breathing.  His  face  and  hands  had  begun  to  swell.  The 
immediate  cause  of  death  was  pulmonary  apoplexy.  The  heart  was 
found  in  a  state  of  dilated  hypertrophy,  and  the  mitral  valves  had 
been  converted  into  a  calcareous  mass,  which  had  left  but  an  extremely 
narrow  chink  for  the  blood  to  pass  through. 

The  next  case  presents,  in  several  respects,  a  striking  similarity. 
A  gentleman,  about  fifty  years  of  age,  who  had  led  a  gay  and  some- 
what dissipated  life,  noticed  that  he  experienced  difficulty  in  breath- 
ing on  the  slightest  exertion.  An  inquiry  into  the  state  of  the  heart 
furnished  a  clue  to  the  dyspnoea.  The  size  of  the  organ  was  evi- 
dently increased,  and  its  rhythm  very  irregular.  The  impulse  was 
strong ;  but  the  sounds  were  normal,  except  near  the  apex,  where, 
taking  the  place  of  one,  was  heard  a  dull  but  very  marked  clack. 
When  the  hand  was  applied  over  this  point,  it  felt  a  vibration  of  very 
much  the  same  character  as  that  which  the  ear  could  hear,  and,  like 


430  MEDICAL  DIAGNOSIS. 

this,  it  was  only  distinctly  perceptible  at  or  near  the  apex  of  the 
organ.  The  diagnosis  of  disease  of  the  mitral  valves  was  made,  and 
it  proved  to  be  correct.  The  dyspnoea  became  greater  and  greater ; 
the  feet,  and  subsequently  the  abdomen,  were  distended  "with  fluid ; 
and  the  patient  died  with  all  the  symptoms  of  an  unmistakable 
valvular  lesion. 

I  might  cite  more  such  cases  ;  but  these  two  present  the  main 
features  of  all.  All  the  instances  of  valvular  disease  I  have  met  with, 
unaccompanied  by  blowing  sounds,  have  been  instances  of  disease  at 
the  mitral  orifice,  and  of  extreme  narrowing  of  that  orifice.  They 
were  all  attended  with  excessive  irregularity  of  the  action  of  the  heart, 
and  with  hypertrophy.  They  all  produced  difficulty  of  breathing. 
They  all  presented  the  peculiar  clacking  sound  most  marked  near  the 
apex.  In  some,  another  sound,  more  like  that  heard  in  health,  fol- 
lowed it ;  in  others,  not.  In  some,  the  blowing  sound  gradually  dis- 
appeared ;  in  others,  none  was  perceived  when  first  examined ;  and 
in  others,  again,  it  could  be  caught  occasionally,  as  a  very  short  whiff, 
along  with  the  clacking  sound.  In  all,  the  impulse  was  strong  and 
very  variable  in  its  rhythm,  and  a  peculiar  movement  was  felt  near 
the  seat  of  the  apex, — not  the  purring  tremor  that  so  commonly 
accompanies  the  movements  of  a  heart  the  valves  of  which  are  dam- 
aged, but  a  more  localized  vibration,  similar  to  the  sound  the  ear  hears. 

These  cases  are  probably  of  the  same  nature  as  those  that  are 
every  now  and  then  reported  as  valvular  lesions  in  which  the  sounds 
of  the  heart  were  normal.  I  cannot  think  that  with  a  disease  of  the 
valves  they  ever  are  so.  There  may  be  no  blowing  sounds  present, 
but  the  sounds  of  the  valve  affected  must  be  different  from  what  they 
are  in  health ;  and  it  may  be  said  again,  in  all  truth,  that  to  hear  the 
natural  sounds  of  the  heart  well  defined  is  to  be  able  to  exclude  a 
valvular  disease. 

Valvular  disease  may  be  at  times  suddenly  developed,  from  rupture 
of  a  valvulet  or  of  a  papillary  muscle  by  a  severe  strain.  I  have  known 
such  cases  to  happen  where  there  was  nothing  in  the  history  to  lead 
to  the  belief  of  previous  disease,  though  often  there  is  some  preceding 
disorganization,  such  as  a  granular  or  a  fatty  change.  One  of  the 
most  striking  diagnostic  features  is  the  quickly  developed  organic 
murmur  attending  the  signs  of  disordered  circulation  and  cardiac 
distress ;  another,  the  occurrence  of  pain  in  the  region  of  the  heart. 
Rupture  may  happen  in  the  affected  valve  of  an  ulcerative  endo- 
carditis without  any  extraordinary  strain.  The  previous  history,  the 
sudden  aggravation  of  the  cardiac  symptoms,  will  furnish  an  explana- 
tion of  the  accident. 


DISEASES  OF  THE  HEART.  431 

Let  me  also  here  briefly  discuss  another  question, — whether  the 
valvular  affection  shows  any  signs  by  which  we  can  recognize  it  before 
the  develojiment  of  a  murmur.  We  cannot  do  so  with  any  certainty ; 
although  marked  alteration^such  as  dulness  of  sound  confined  to  or 
most  obvious  at  a  particular  valve,  the  signs  of  preceding  or  of  grow- 
ing hypertrophy,  and,  where  the  aortic  valves  are  concerned,  a  distinct 
accentuation  of  the  second  sound,  while  the  first  has  become  dull 
and  changed — might  make  us  suspect  what  is  about  to  happen.  A 
doubling  of  either  the  first  or  the  second  sound,  especially  of  the  latter, 
is  often,  according  to  the  observations  of  Sansom,  an  early  sign  of  the 
development  of  mitral  narrowing.  Gibson  ^  dwells  on  the  doubling  of 
the  second  pulmonary  sound  in  mitral  obstruction  at  any  stage,  an^ 
on  the  great  tendency  to  the  appearance  and  disappearance  of  the 
doubling ;  while  Broadbent  ^  maintains  that  a  mitral  systolic  murmur 
which  is  retarded,  following  the  first  sound  at  a  brief  interval,  shows 
that  the  changes  in  the  valve  are  slight. 

Displacements  of  the  Heart. 

The  heart  is  a  very  movable  organ.  Its  apex  is  tilted  upward  by 
an  enlarged  liver,  by  an  abdominal  tumor,  or  by  a  pericardial  effusion. 
It  gravitates  towards  the  median  line  when  the  walls  of  the  heart  have 
increased  in  weight  and  firmness.  But  these  changes  are  hardly  of  a 
nature  to  attract  as  much  attention  as  finding  a  heart  beating  on  the 
right  side  of  the  sternum. 

Now,  it  is  not  very  uncommon  to  meet  with  it  there ;  and  the 
question  immediately  arises,  What  does  this  strange  alteration  in  its 
situation  signify,  and  how  is  it  brought  about?  It  is  usually  pro- 
duced by  pressure  exercised  on  the  heart  by  accumulations  of  fluid 
or  of  air  in  the  left  pleural  cavity,  and  therefore  denotes,  as  a  rule,  a 
pleuritic  effusion  or  a  pneumothorax  of  the  left  side,  and  is  accom- 
panied by  distention  of  that  side.  In  rarer  instances,  the  heart  is 
pushed  across  by  a  highly  distended  emphysematous  lung ;  in  still 
rarer  instances,  it  is  drawn  over  to  the  right  side  by  a  shrinking  of 
the  lung,  attended  with  dilatation  of  the  bronchial  tubes,  the  so-called 
pulmonary  cirrhosis.  It  is  sometimes  found  on  the  right  side,  because 
it  has  been  forced  there  by  a  pleuritic  effusion  and  has  formed  adhe- 
sions, and  when  the  fluid  was  absorbed  it  was  unable  to  return  to 
its  natural  place.  In  this  case  the  left  side  will  be  markedly  re- 
tracted, and  not  the  right,  as  it  is  if  cirrhosis  of  the  right  lung  be  the 
cause  of  the  abnormal  position  of  the  heart. 

1  Diseases  of  the  Heart,  1898.  ^  Heart  Disease,  1898. 


432  MEDICAL  DIAGNOSIS. 

The  displacement  may  further  have  been  brought  about  by  a 
cancerous  or  an  aneurismal  tumor,  or  by  any  of  the  abdominal 
viscera  having  slipped  into  the  chest  through  a  hernial  opening  in  the 
diaphragm  ;  or  it  may  be  congenital.  But  these  all  are  causes  which 
seldom  exist.  Pratically  speaking,  transpositions  of  the  heart  are 
met  with  in  conection  With  diseases  of  the  lungs.  M^e  shall  merely 
add  that  a  congenital  displacement  cannot  be  diagnosticated  unless 
all  other  causes  capable  of,  producing  a  displacement  have  been 
proved  to  be  absent ;  and  that  a  dislocated  heart  is  able  to  perform 
all  its  functions.  It  may  even  be  attacked  by  acute  disease  ;  the  rec- 
ognition of  which,^  under  such  circumstances,  belongs  to  the  triumphs 
of  physical  diagnosis, 

SECTION  III. 

THORACIC    ANEURISM, 

An  aneurism  of  the  aorta,  whether  caused  by  a  disease  of  the 
coats  of  the  artery  or  not,  whether  true  or  false,  may  affect  any  part 
of  the  vessel.  Yet  it  is  chiefly  at  the  ascending  portion  and  at  the 
arch  that  it  is  met  with.  When  it  occurs  just  after  the  artery  has 
left  the  heart,  it  is  prone  to  elude  discovery.  Higher  up,  nearer  to  or 
at  the  arch,  it  more  rarely  escapes  detection.  The  tumor  manifests 
itself  by  a  local  bulging,  varying  in  extent  and  situation  according  to 
the  extent  and  situation  of  the  aneurism,  A  single  rib  alone  may  be 
raised,  or  nothing  but  a  fulness  may  be  observed.  But  some  prom- 
inent spot  is  generally  detected,  and  when  this  is  percussed  it  is  more 
resistant,  and  returns  a  duller  sound,  than  normal.  Yet  neither  the 
bulging  nor  the  dulness  on  percussion  is  of  as  much  significance  as 
finding  a  distinct  pulsation  remote  from  the  beat  of  the  heart.  Every 
time  the  latter  is  perceived,  an  impulse  is  communicated  to  the  finger 
at  the  poi^t  in  the  chest  wahs  which  appears  to  project;  that  is, 
usually  on  the  right  side  of  the  sternum  in  the  second  intercostal 
space,  or  in  the  same  interspace  on  the  left  side,  or  immediately 
under  the  top  of  the  bone.  Occasionally  the  beat  is  double,  at  times 
so  violent  as  to  shake  the  head  of  the  listener,  and  almost  always, 
unless  the  aneurism  be  filled  with  solid  clots,  stronger  than  the  beat 
of  the  heart. 

The  impulse  may  be  accompanied  by  a  distinct  thrill.  But  this  is 
not  always  present,  and,  when  present,  is  not  always  constant,  since 
it  may  disappear  and  reappear.  It  is  thus  a  serious  mistake  to  regard 
the  thrill  as  the  requisite  sign  of  an  aneurismal  enlargement;  yet 

1  As  by  Stokes.     See  Diseases  of  the  Heart,  p.  463. 


THORACIC  ANEURISM.  433 

there  is  no  mistake  more  common,  except,  perhaps,  one, — to  consider 
that  the  motion  of  the  blood  in  the  sac  must  necessarily  engender  a 
murmur.  The  ear,  applied  over  the  prominence,  hears  often  nothing 
that  in  the  least  resembles  a  murmur,  but  sounds  like  those  of  the 
heart,  sometimes  two,  the  first  weighty  and  prolonged ;  sometimes 
but  one,  and  that  one  longer  and  more  intense  than  the  correspond- 
ing first  sound  over  the  ventricles. 

Thus,  then,  neither  thrill  nor  murmur  is  essential  to  the  diagnosis 
of  an  aneurism.  What  is  much  more  essential  is  to  find  two  points 
of  pulsation  in  the  chest, — two  hearts,  apparently,  each  with  its  own 
distinct  beat,  its  own  distinct  sounds. 

An  aneurismal  tumor  in  the  chest  gives  rise  to  symptoms  which 
vary  somewhat  according  to  its  seat  and  size.  Prominent  among 
them  stand  those  occasioned  by  pressure.  The  sac  presses  on  the 
adjacent  air-tubes,  apd  shortness  of  breathing,  or  peculiar  cough  and 
signs  counterfeiting  those  of  a  chronic  laryngeal  disease,  are  the  result ; 
or  it  presses  on  the  oesophagus,  and  the  patient  suffers  from  difficulty 
in  swallowing ;  or  it  presses  on  the  subclavian  artery,  and  the  pulses 
at  the  two  wrists  are  noticed  to  be  strikingly  different  both  in  volume 
and  in  time  ;  or  on  the  carotid,  and  pain  in  the  head,  dulness  of  mind, 
occasional  giddiness,  and  flashes  of  light  before  the  eyes  are  com- 
plained of;  or  on  the  venous  trunks,  and  the  superficial  veins  of  the 
neck  and  thorax  are  seen  to  be  engorged,  and  the  skin  becomes  very 
puffy  and  swollen ;  or  on  the  trunk  of  the  sympathetic  nerve  or  on 
its  ganglia  and  their  communications,  and  marked  contraction,  or,  in 
rarer  instances,  dilatation,  of  the  pupil  of  the  eye  on  the  side  of  the 
aneurismal  swelling,  is  perceived,  or  unilateral  sweating  becomes  an 
annoying  complication.  All  these  signs,  then,  denote  pressure,  and 
pressure  connected  with  a  pulsating  tumor  in  the  chest  means  an 
aneurism. 

I  say  with  a  pulsating  tumor,  because  a  cancerous  or  other  intra- 
thoracic morbid  gi^owth  may  produce  exactly  the  same  signs  of  com- 
pression as  aneurismal  tumor, — the  same  stridor,  the  same  cough, 
the  same  feebleness  of  respiration  in  one  lung  from  partial  oblitera- 
tion of  its  bronchial  tube.  But  the  solid  tumor,  large  though  it  be, 
does  not  pulsate,  or  if  it  do,  pulsates  but  very  feebly,  and  not  with 
the  heaving  motion  of  a  distending  aneurismal  sac.  The  tumor, 
which  for  the  most  part  has  its  seat  in  the  mediastinum,  renders  a 
large  surface  dull  on  percussion,  and  communicates  a  much  greater 
feeling  of  resistance  to  the  percussing  finger.  Yet  the  ear  listens  in 
vain  over  the  prominence  for  the  weighty  sound  with  each  beat  of  the 
heart,  or  for  the  hoarse  murmur  of  the  blood  streaming  through  the 


434  MEDICAL  DIAGNOSIS. 

sac.  It  is  only  where  a  solid  growth  presses  on  the  artery  that  any 
murmur  is  perceived,  and  there  is  always  a  distinct  second  aortic 
sound.  Further,  a  tumor  is  not  confined  to  the  course  of  the  aorta ; 
it  is  more  commonly  connected  with  a  distended  state  of  the  veins  of 
the  neck  and  thorax,  and  with  cedema  of  the  arm  and  chest ;  the  pain 
it  occasions  is  often  more  continued,  and  less  neuralgic  in  its  nature, 
and  the  dyspnoea  is  not  infrequently  paroxysmal.  Moreover,  as  most 
thoracic  tumors  are  cancerous,  the  violent  constitutional  disturbance, 
the  formation  of  external  swellings,  the  enlargement  of  the  glands  in 
the  axilla  and  the  neck,  and  the  peculiar  currant-jelly  expectoration, 
aid  us  in  arriving  at  a  correct  conclusion.  Sarcoma,  lymphomata, 
and  lymphadenomata  of  the  mediastinum  come  next  in  frequency  to 
cancer.^  They  all  tend  to  grow  inward  rather  than  outward,  and 
affect  the  anterior  mediastinum  far  oftener  than  the  other  two  spaces. 
Then  the  history  is  of  some  value  in  the  diagnosis.  In  aneurism  it 
points  to  gout,  to  aortitis,  to  alcoholism,  to  syphilis,  to  strain,  to  an 
embolic  infarct,  to  infectious  arteritis  from  mycotic  invasion  of  the 
aorta,  and  there  is  generally  some  evidence  of  arterial  degeneration. 
In  tumors  of  the  mediastinum,  Wintrich's  tracheal  sound,  the  sound 
which  issues  from  the  trachea  on  percussing  the  chest,  can  be  elicited 
by  moderate  percussion  over  the  manubrium  during  the  act  of  inspi- 
ration. The  same  may  be,  however,  also  found  in  aneurism  of  the 
ascending  arch  of  the  aorta.^ 

The  most  difficult  diagnosis — it  is  often  an  impossible  one — is  be- 
tween an  aneurism  filled  with  solid  clots  and  a  tumor.  The  history 
of  the  case  is  here  of  the  greatest  importance ;  and  there  is  generally 
less  .pain  in  these  altered  aneurisms  than  in  tumor.  The  physical 
signs  will  not  help  us.  As  a  rule,  it  may  be  said  that  we  do  not  meet 
in  the  latter  with  the  ringing  second  aortic  sound,  or  the  shock  ^vith 
this,  which  happens  in  aneurism, — happens  mostly  even  when  it  is 
filled  with  clots. 

As  regards  abscess  of  the  mediastinum,  we  do  not  find  the  pressure 
signs  generally  so  marked  as  in  aneurism,  and  we  may  be  able  to  de- 
tect fluctuation  at  the  edge  of  the  sternum  or  at  the  suprasternal 
notch.  The  pain  is  usually  very  great ;  the  elevation  of  temperature 
is  significant.  The  sounds  over  the  mass  are  not  those  of  an  aneu- 
rismal  sac ;  there  are  certainly  no  distinctive  murmurs,  and  we  find 
no  marked  expansile  pulsations.  This  absence  of  distinct  pulsation 
was  the  main  point  of  dissimilarity  between  an  aneurism  and  an  ab- 

^  Hare,  Mediastinal  Disease,  1889. 

2  C.  F.  Hoover,  Amer.  Journ.  Med.  Sci.,  Oct.  1899. 


THORACIC  ANEURISM.  435 

scess  of  the  mediastinum  in  a  case  some  time  since  under  my  care, 
which,  after  lasting  a  year,  and  simulating  aneurism  most  closely  in 
the  pain,  the  dulness  on  percussion,  the  difficulty  of  breathing  and 
of  swallowing  and  the  altered  voice,— having,  therefore,  pressure 
signs  much  more  marked  than  usual,— got  well  by  the  abscess  break- 
ing internally  and  the  discharge,  as  expectoration,  of  large  amounts 
of  purulent  matter.  In  inflammatory  thickening  of  the  mediastinum 
the  impulse  of  the  heart  is  weak  and  the  sounds  are  faint.' 

The  obvious  inequality  of  the  pupils,  which  is  found  in  a  certain 
number  of  cases  among  the  signs  of  an  aneurism,  is  of  little  aid  in  a 
differential  diagnosis  from  intrathoracic  tumor,  for  a  thoracic  cancer 
has  been  noted  to  occasion  the  same.'  The  rarity  of  a  non-aneuris- 
mal  tumor  in  the  chest  is,  however,  very  great;  and,  practically 
speaking,  when  the  signs  of  intrathoracic  tumor  are  met  with  we 
shall  be  generally  correct  in  thinking  that  it  is  an  aneurism  we  have 
to  treat,  even  should  the  pulsations  not  be  very  obvious. 

The  sphygmograph  will  at  times  aid  us  in  the  diagnosis  of  an 
aneurism,  though  its  value  is  not  on  the  Avhole  great.  Its  most  dis- 
tinct significance  is  in  showing  clearly  the  difference  between  the  two 
pulses.  Of  one  radial  the  sphygmogram  may  be  normal ;  the  other 
tracing  furnishes  a  characteristic  record,— a  sloping  up-stroke,  a 
rounded  apex,  an  obliteration  of  the  secondary  curves. 

Another  sign  of  aneurism  which  has  been  much  studied,  and 
especially  by  MacDonnell,^  is  the  so-called  tracheal  tugging.  To 
obtain  it  the  cricoid  cartilage  is  firmly  grasped  and  the  trachea  put  on 
the  stretch  by  pressing  upward.  If  an  aneurism  is  adherent  to  it  or 
near  it,  a  significant  tugging  will  be  felt.  In  deep-seated  aneurisms 
this  sign  is  of  special  value ;  particularly  significant  is  it  of  aneurism 
of  the  transverse  portion  of  the  arch.  But  it  is  not  absolutely  char- 
acteristic of  aneurism.  It  has  been  found  by  Grimsdale*  and  by 
Ewart^  m  other  conditions,  and  even  in  healthy  subjects. 

Let  us  suppose  that  we  are  satisfied,  owing  to  a  marked  impulse, 
that  we  have  not  a  solid  growth  or  an  abscess  to  deal  with,  can  we 
say  that  it  is  an  aneurismal  enlargement  ?  If  there  be  also  swelling 
and  signs  of  pressure,  we  can ;  should  these  not  exist,  we  cannot  be 
so  sure.     For  a  pulsation  m  the  chest  not  immediately  over  the  region 

1  Wilson  Fox,  Treatise  on  Diseases  of  the  Lungs. 

2  MacDonnell,  Montreal  Medical  Chronicle,  June,  1858  ;  Gairdner,  Chnical  Med- 
icine, and  Ogle,  Medico-Chirurgical  Transactions,  vol.  xli. 

'^  Lancet,  March,  1891. 

*  Practitioner,  London,  Feh.  1892. 

s  British  Medical  .Journal,  March,  1892. 


436  MEDICAL  DIAGNOSIS. 

of  the  heart  may  be  owing  to  other  causes.  Where  the  aortic  valves 
are  insufficient,  there  may  be  a  pulsation  in  the  aorta ;  an  empyema 
may  pulsate ;  a  dilated  auricle  may  occasion  an  impulse  separate 
from  that  of  .the  ventricles  ;  a  pulmonary  artery  surrounded  by  con- 
solidated lung  may  distinctly  exhibit  its  beat.  In  all  of  these  the  signs 
of  pressure  on  the  surrounding  parts  are  wanting ;  and,  on  the  other 
hand,  they  show  phenomena  which  an  aneurism  lacks. 

Insufficient  aortic  valves  are  accompanied  by  hypertrophy  of  the 
left  ventricle.  So  is  at  times  a  thoracic  aneurism  ;  but,  instead  of  the 
throbbing  at  the  upper  anterior  part  of  the  chest  being  attended,  as 
in  aneurismal  swelling,  with  a  natural  or  with  an  unequal  beat  at  the 
wrist,  there,  as  well  as  in  the  larger  trunks  in  the  neck  and  arms, 
is  perceived  that  strong  and  peculiar  pulsation  so  characteristic  of 
inadequate  aortic  valves.  Then,  again,  a  murmur  is  invariable  in  this 
aifection,  and  is  usually  a  loud  double  murmur,  most  distinct  at  the 
right  base  of  the  heart,  and  associated  with  a  double  murmur  in  the 
femorals  made  evident  by  pressure  with  the  stethoscope.  This  is 
very  rare  in  aneurism  of  the  aorta ;  moreover,  the  murmur  heard 
over  an  aneurismal  pulsation  is  better  marked  over  its  seat  than  over 
the  heart,  and  is  mostly  single,  short,  hoarse  and  of  low  pitch,  sys- 
toHc,  only  in  very  rare  instances  diastolic.  It  differs  in  distinctness  as 
well  as  in  quality  from  the  murmur  discerned  at  the  base  of  the 
heart,  which  is  transmitted  from  the  aneurism,  or  depends  upon  co- 
existing cardiac  disease.  Then  the  sphygmographic  tracings  may  be 
also  of  value.  Those  of  aortic  regurgitation  are  characteristic ;  while 
an  obhque  line  of  ascent,  a  loss  of  the  summit  wave,  and  a  modifica- 
tion of  the  dicrotism  are  usual  when  an  aneurism  is  seated  on  a  main 
trunk  after  its  origin  froni  the  aorta.  When  the  aorta  is  dilated,  as 
well  as  its  valves  diseased,  the  diagnosis  as  regards  aneurism  is  much 
more  difficult.  But  even  then  we  lack  the  distinct  throbbing,  the 
signs  of  pressure,  and  the  unequal  pulses. 

Coarctation  or  constriction  of  the  aorta,  which  in  rare  cases  is  asso- 
ciated with  the  valvular  affection,  may  be  here  mentioned.  It  gener- 
ally happens  just  at  or  below  the  insertion  of  the  ductus  arteriosus, 
and  furnishes  as  its  only  special  signs  a  dilatation  of  certain  collateral 
vessels  at  the  upper  part  of  the  thorax,  and  feeble,  retarded  pulsation 
of  the  femorals.  The  arteries  of  the  head  and  neck,  as  well  as  the 
epigastric  and  mammary  arteries,  throb,  and  there  may  be  a  marked 
thrill  at  the  upper  part  of  the  chest  near  the  sternum,  and  a  murmur 
there  louder  than  over  the  heart ;  but  pressure  signs  are  absent,  and 
the  dilated  vessels  are  often  the  seat  of  a  purring  noise. 

A  pulsating  enlpyema  is  seldom  met  with ;  yet  a  collection  of  fluid 


THORACIC  ANEURISM.  437 

in  the  cavity  of  the  chest  may  vibrate  with  the  motion  of  the  heart, 
and  throb  with  such  distinctness  as  closely  to  simulate  an  aneurism. 
To  determine  the  real  nature  of  the  pulsation  in  these  cases,  we  must 
attach  importance  to  the  situation  of  the  expanding  mass,  which  is 
not  often  that  of  an  aneurism,  and  to  the  signs  which  point  out  that 
liquid  has  accumulated  within  the  pleural  sac.  We  also  note  the  cir- 
cumstance that  over  the  seat  of  impulse  there  are  no  peculiarly 
marked  sounds,  no  murmurs,  no  thrill ;  moreover,  the  beat,  which  is 
wide-spread,  is  not  apt  to  be  so  strong  as  that  of  the  heart,  which  is 
displaced.  The  pulsation  may  happen  both  in  acute  and  chronic 
pleurisy,  and  be  associated,  as  in  Osier's  ^  case,  with  persistent  tender- 
ness of  the  thoracic  walls.  There  may  be  a  number  of  these  pul- 
sating tumors.^  Pulsating  pleurisies  are  nearly  always  left-sided  and 
purulent ;  there  is  generally  latent  pneumothorax  present.^  In  one  of 
Wilson's  cases  *  the  pulsation  disappeared  immediately  after  aspiration. 

A  dilated  auricle^  the  walls  of  which  are  at  the  same  time  hyper- 
trophied,  may  give  rise  to  a  movement  separate  from  that  of  the  beat 
of  the  ventricle.  Bouillaud  cites  an  example  of  this  nature,  in  which 
a  double  motion  was  perceptible  in  the  second  intercostal  space  of  the 
left  side,  in  a  person  whose  heart  was  extensively  hypertrophied  and 
whose  mitral  valves  were  indurated.  Such  cases  are  extremely  rare. 
The  signs  of  an  accompanying  valvular  affection  and  of  enlargement 
of  the  ventricles,  and  the  probable  presence  of  dropsy,  would  serve  to 
distinguish  a  dilated  auricle  from  aneurism  of  the  arch.  And  this  is 
the  only  form  of  enlargement  of  the  heart  which  is  likely  to  be  mis- 
taken for  an  aneurism.  In  cases  of  hypertrophy  or  dilatation  as  we 
ordinarily  meet  with  them,  there  is  but  one  motion  discernible, — that 
over  the  ventricles, — and  not  two  beats  at  some  distance  from  each 
other ;  the  signs  of  pressure,  too,  are  wanting.  In  dilatation  of  the 
right  auricle,  Sansom  notes  a  vibration  to  the  right  of  the  sternum  and 
a  wedge-shaped  line  of  dulness  joining  the  dulness  of  the  liver. 

A  pulmonary  ai^tery  surrounded  by  consolidated  lung-tissue  may 
cause — especially  if  the  vessel  be  somewhat  widened — a  distinct  pul- 
sation. But  the  seat  of  the  dulness  near  the  apex  of  the  left  lung ; 
its  non-extension  over  the  median  line  ;  the  limitation  of  the  murmur 
to  the  site  of  the  pulmonary  artery,  or,  in  some  instances,  to  this  ves- 
sel and  the  subclavian ;  the  sharply-defined  second  sound  of  the  pul- 

1  Amer.  Journ.  Med.  Sci.,  Jan.  1889. 

^  Henry,  Proceedings  of  the  Philadelphia  County  Medical  Society,  vol.  iii. 

'  Comby,  Arch.  Gen.  de  Med.,  April,  1889. 

*  Transactions  of  the  Association  of  American  Physicians,  1893. 


438  MEDICAL  DIAGNOSIS. 

monary  artery  in  the  second,  interspace  on  the  left  side  ;  the  symp- 
toms and  physical  signs  of  phthisis,  the  most  common  cause  of  the 
consolidation,  and  a  morbid  condition  which  of  itself  would  appear 
to  exclude  an  aneurism  ;  the  absence  of  pain  and  of  the  phenomena 
caused  by  pressure, — all  these  prove  the  murmur  and  the  pulsation 
not  to  be  due  to  an  aortic  aneurism.  Absence  of  pain  and  of  pressure 
signs,  and  accentuation  of  the  second  sound,  are  also  the  chief  signs 
by  which  we  distinguish  those  comparatively  rare  cases  of  murmur  in 
the  second  interspace,  close  to  the  left  of  the  sternum,  which  are  due 
to  retraction  of  the  lung  and  uncovering  of  the  heart  and  pulmonary 
artery.  The  murmur,  which  has  been  specially  studied  by  Quincke  ^ 
and  Balfour,^  is  systolic  and  loud,  and  mostly  disappears  on  deep  in- 
spiration. The  pulsation  is  marked,  though  not  so  strong  as  that  of 
the  heart  ;  the  singular  murmur  is  supposed  to  be  owing  to  compres- 
sion of  the  pulmonary  artery  by  the  heart  during  the  systole.  In 
many  respects  it  is  like  the  murmur,  which  I  have  elsewhere  investi- 
gated,^ heard  over  the  pulmonary  artery  in  certain  lung  affections. 

Another  abnormal  condition  which  may  be  mistaken  for  an 
aneurism  is  a  malformation  of  the  chest,  particularly  when  produced 
by  great  prominence  of  the  upper  part  of  the  sternum.  This  error 
is  more  especially  apt  to  occur  if  there  be  coexisting  disturbance  of 
the  heart,  whether  of  functional  or  of  organic  origin.  I  have  seen 
cases  where  the  beating  of  the  arteries  of  the  neck,  accompanied  by 
an  enlargement  of  the  thyroid  gland  and  by  cardiac  palpitation,  was 
believed  to  be  an  aneurism,  mainly  because  it  was  combined  Avith 
very  decided  prominence  of  the  upper  portion  of  the  sternum.  But 
there  were  no  distinctly  localized  tumefaction  and  pulsation,  no  altered 
sounds,  no  signs  of  pressure.  I  have  also  met  with  instances  in  which 
the  active  pulsation  of  the  thyroid  gland,  both  in  exophthalmic  and  in 
ordinary  goitre,  gave  rise  to  the  idea  of  an  aneurism,  but  in  which  no 
change  of  the  chest  walls  existed.  In  such  cases  the  carotids  and 
radials  beat  equally ;  a  blowing  murmur,  attended  by  a  continuous 
hum,  is  heard — certainly  in  instances  of  exophthalmic  goitre — over 
the  enlarged  gland ;  there  is  nowhere  a  point  of  localized  pulsation, 
and  there  are  no  signs  of  pressure. 

Malposition  of  the  aorta,  due  to  rickets,  may  simulate  an-  aneurism 
closely.     Balfour  ^  has  pointed  out  how  misleading  may  be  the  abnor- 

^  Berliner  klinische  Wochenschrift,  1870. 

^  Lectures  on  Diseases  of  the  Heart,  London,  1876. 

'  Amer.  Journ.  Med.  Sci.,  Jan.  1859. 

*  Diseases  of  the  Heart,  London,  1876. 


THORACIC  AJS^EURISM.  439 

mal  pulsation  with  the  dulness  on  percussion,  and  the  right-sided 
prominence  of  the  chest.  Moreover,  thrill,  murmurs  loudest  over  the 
pulsating  mass,  and  cardiac  hypertrophy,  may  coexist.  We  must  be 
guided  in  our  opinion  by  the  history  of  the  case  ;  by  the  distortion  of 
the  spine  ;  by  the  extended  superficial  dulness  on  percussion,  out  of 
proportion  to  the  extent  and  strength  of  the  pulsation  of  the  tumor, 
which  is  less  forcible  than  that  of  the  heart ;  by  the  displaced  position 
of  the  heart,  which  is  tilted  upward  and  thrown  over  more  to  the 
right ;  and  especially  by  the  absence  of  any  signs  of  pressure. 

The  signs  of  pressure  play,  then,  a  very  important  part  in  the 
diagnosis  of  an  aneurism.  They  are  rarely  wanting,  although  they  do 
not  always  manifest  themselves  in  the  same  manner :  sometimes  it  is 
bone,  sometimes  lung,  sometimes  oesophagus,  sometimes  nerve-fibre, 
which  bears  the  brunt  of  the  distending  swelling.  These  signs  of 
pressure  are  not  present  if  the  sac  be  very  small ;  or  not  prominent, 
if  the  artery  be  simply  dilated,  in  which  case  nothing  but  a  constantly 
pulsating  tumor  can  be  detected.  At  times  evidences  of  compression 
may  be  recognized  when  no  throbbing  swelling  can  be  discerned,  and 
from  them  the  true  nature  of  the  case  inferred.  Whenever,  indeed, 
obstinate  and  anomalous  thoracic  symptoms,  which  might  be  ex- 
plained by  the  presence  of  an  aneurismal  sac,  occur  in  a  person 
whose  lungs  and  heart  appear  to  be  in  every  respect  sound  and 
whose  general  health  is  not  materially  affected,  we  may  suspect  an 
aneurism  to  be  the  source  of  the  disorder.  So,  too,  if  there  be 
strange  laryngeal  or  oesophageal  manifestations. 

The  symptoms  of  chronic  laryngitis  especially  are  at  times  aston- 
ishingly simulated,  and  it  may  happen  that  the  patient,  trusting  to  his 
feelings,  refers  obstinately  to  the  chest  as  the  seat  of  the  disorder, 
while  the  physician  as  obstinately  sees  nothing  but  the  presumed 
affection  of  the  larynx.  There  is,  as  in  chronic  laryngeal  disease,  al- 
teration of  the  voice  mth  cough  ;  but  the  voice  frequently  retains  much 
of  its  natural  character.  Hoarse  it  may  be,  but,  as  the  pressure  varies, 
it  alters  rapidly  both  in  pitch  and  in  power.  The  cough  is  commonly 
paroxysmal,  and  has  a  ringing  sound.  Dyspnoea  is  a  constant  symp- 
tom. It  is  often  attended  with  wheezing  or  stridulous  breathing, 
which  is  not  persistent,  and  is  sometimes  produced  only  after  a  deep 
inspiration.  The  stridor,  however,  as  Stokes  points  out,  differs  from 
that  of  an  obstructive  disease  of  the  larynx  by  its  seeming  to  issue 
from  the  notch  at  the  sternum,  and  not  from  above,  from  the  larynx 
itself.  If,  in  addition,  the  respiration  be  found  to  be  markedly  unequal 
in  the  two  lungs,  the  diagnosis  of  aneurism  may  be  ventured  upon ; 
and  it  will  be  confirmed  by  finding  no  change  in  the  larynx  sufficient 


440  MEDICAL  DIAGNOSIS. 

« 

to  account  for  the  laryngeal  symptoms,  or  such  a  change — paralysis 
of  only  one  cord,  for  instance,  or  paralysis  of  an  abductor  on  one 
side — as  could  be  readily  explained  by  pressure  on  one  recurrent 
nerve.^  Of  course,  the  detection  of  dulness  on  percussion,  of  sounds 
stronger  than  or  otherwise  different  from  those  in  the  cardiac  region, 
or  the  occurrence  of  a  hemorrhage,  would  place  the  diagnosis  beyond 
doubt.  A  systolic  sound  or  thud  in  the  brachial  artery  is  also  a  sign 
to  which  importance  may  be  attached.^ 

In  some  cases  of  aneurism,  pain  is  among  the  earliest  symptoms, 
and  the  patient  complains  much  of  it  before  there  is  a  single  physical 
sign  indicative  of  the  presence  of  a  tumor.  The  pain  is  dependent 
upon  pressure  on  the  nervous  filaments :  it  may  shoot  towards  the 
shoulder  or  the  neck,  along  the  arm,  or  deep  into  the  centre  of  the 
chest.  Dull,  deep  pain,  boring  and  constant,  occurs  when  the  press- 
ure of  the  sac  is  leading  to  absorption  of  the  vertebrae.  Over  the  seat 
of  the  swelling  there  is  often  pain,  with  great  tenderness. 

The  severity  of  the  pain  may  give  rise  to  emaciation  and  fatal 
exhaustion  ;  but  usually  the  patient's  life  is  cut  short  by  the  aneurism 
bursting,  either  externally  or  into  the  trachea,  bronchial  tubes,  oesoph- 
agus, pericardium,  pleura,  pulmonary  artery,  or  spinal  canal.  Yet  it 
is  not  always  the  first  rent  which  leads  to  the  fatal  issue  ;  this,  when 
the  aneurism  breaks  externally,  may  not  happen  for  weeks  after  the 
accident.^ 

Now,  can  we  foretell  the  course  of  an  aneurism,  and  the  probable 
mode  of  death  it  is  likely  to  occasion  ?  We  cannot ;  since  we  cannot 
determine  accurately  its ,  seat  nor  know  what  tissues  are  likely  to  be 
encroached  upon.  It  is  true  that,  when  the  swelling  gives  rise  to 
phenomena  like  those  of  angina  pectoris,  we  may  surmise  it  to  be  in 
the  ascending  portion  of  the  aorta  and  near  the  cardiac  plexus  of 
nerves,  and  look  for  its  breaking  into  the  pericardium  or  the  pul- 
monary artery ;  when  it  is  accompanied  by  laryngeal  stridor  or  other 
laryngeal  symptoms,  it  probably  involves  the  posterior  and  lower  por- 
tions of  the  arch,  and  will  cause  death  by  strangulation  or  by  exhaus- 
tion ;  when  it  produces  much  dyspnoea,  it  is  apt  to  be  seated  in  the 
descending  part  of  the  arch,  and  death  may  take  place  by  the  aneu- 
rism bursting  into  a  bronchial  tube,  or  by  pneumonia.  But  m  regard 
to  all  these  matters  we  can  do  little  else  than  conjecture. 


^  In  the  chapter  on  Diseases  of  the  Larynx,  the  forms  of  laryngeal  palsy  from 
an  aneurism  have  been  more  specially  examined  into. 
^  Glascow,  New  York  Medical  Journal,  Sept.  1894. 
3  Webb,  Amer.  Journ.  Med.  Sci.,  Oct.  1874. 


s  p 


CD     B 


o 


THORACIC  ANEURISM.  441 

An  aneurism  of  the  descending  aorta^  between  the  arch  and  the 
diaphragm,  produces,  if  extensive,  dulness  on  percussion  and  bulging 
posteriorly,  and  may  exhibit  the  same  physical  signs  and  symptoms  as 
an  aneurism  in  the  neighborhood  of  the  arch.  A  gnawing  sensation 
in  the  vertebrae  has  been  especially  noticed ;  so  have  difficulty  in 
swallowing  and  stridor  on  the  left  side  of  the  chest.  Yet,  in  spite  of 
■the  most  careful  scrutiny,  an  aneurism  of  the  descending  aorta  often 
escapes  detection,  or  its  physical  signs,  as  a  case  recorded  by  Walshe  ^ 
proves,  may  exist  to  the  right  instead  of  to  the  left  of  the  spinal  col- 
umn, because  the  vessel  has  been  dragged  across  the  median  line  by 
its  enlargement.  In  aneurism  of  the  descending  thoracic  aorta  near 
the  diaphragm,  we  have  expansile  pulsation,  but  not  stridor  ;  there  are, 
as  Gibson^  points  out,,  marked  signs  of  compression  with  vesiculo- 
bronchial or  bronchial  breathing,  and  increased  vocal  resonance  at  the 
lower  part  of  the  left  lung.  In  aneurisms  of  the  descending  aorta, 
perhaps  even  more  than  in  aneurisms  of  other  portions  of  the  aorta, 
we  get  the  greatest  help  from  the  Roentgen  rays,  and  cases  that  can- 
not be  otherwise  recognized  can  thus  be  diagnosticated. 

An  aneurism  of  the  heart  may  in  exceptional  instances  produce 
localized  bulging  in  the  cardiac  region.  But,  whether  it  does  so  or 
not,  it  is  beyond  the  reach  of  positive  diagnosis.  We  may  suspect  it 
if  the  bulging  have  been  preceded  by  signs  of  fibroid  degeneration  of 
the  walls  of  the  heart.  Obstructed  coronaries  producing  the  myo- 
cardial changes  are  its  most  common  cause.  Pericarditis  with  ad- 
hesions near  the  aneurism  has  been  also  noticed.  In  a  number  of 
instances  we  have  a  syphilitic  history. 

In  rare  instances  we  find  a  varicose  aneurism  communicating  with 
either  the  ascending  or  the  descending  vena  cava.  These  aneurisms 
mostly  present  the  ordinary  signs  of  a  thoracic  aneurism  ;  but,  in  ad- 
dition, great  venous  enlargement  above  the  diaphragm,  with  oedema  of 
the  face  and  hands  and  arms  ;  a  purple  hue  of  the  face  and  the  upper 
part  of  the  body,  and  spots  of  ecchymosis  in  the  skin  ;  a  jerking  pulse  ; 
a  purring  thrill  ;  and  a  whirring  systolic  murmur,^  diffused  all  over  the 
front  of  the  chest.  The  oedema  and  the  symptoms  of  venous  disturb- 
ance come  on  suddenly.  In  occlusion  of  the  vena  cava  the  greart 
venous  distention  is  not  accompanied  by  the  physical  signs  of  aneurism, 
nor  by  thrill,  nor  by  cyanosis  and'  oedematous  swelling.* 

■*  Diseases  of  the  Heart. 
^  Diseases  of  the  Heart  and  Aorta,  1898. 

^  As  in  Mayne's  case,  Dublin  Quart.  Journ.  of  Med.  Sci.,  Nov.  1853  ;  also  in 
Glascow's  case,  St.  Louis  Courier  of  Med.,  Jan.  1885. 

*  Arthur  V.  Meigs's  case,  Transact.  Coll.  of  Phys.  of  Pliila..  1886. 


442  MEDICAL  DIAGNOSIS. 

Let  us,  in  conclusion,  glance  at  the  other  kinds  of  aneurism  within 
the  thorax, — that  of  the  innominate  and  that  of  the  pulmonary  artery. 

An  aneurism  of  the  innominate  artery  is  strictly  limited  to  the  right 
side  of  the  body.  It  differs  from  that  of  the  arch  by  the  higher  situa- 
tion of  the  pulsating  swelling ;  by  the  displacement  of  the  clavicle ;  by 
the  comparative  absence  of  signs  of  pressure  on  the  larynx  and 
oesophagus  ;  and  by  the  fact  that  compression  of  the  right  subclavian 
and  carotid  diminishes  the  beat  of  the  tumor,  while  it  exerts  no  effect 
on  an  aortic  aneurism.  Such  are,  at  all  events,  the  marks  of  distinc- 
tion indicated  by  the  observations  in  Holland's '^  excehent  memoir. 
An  additional  sign  is  mentioned  by  Wardrop.^  It  is  that  when  the 
innominate  is  affected,  the  difficulty  will  appear  first  on  the  tracheal 
side  of  the  sterno-mastoid ;  but  on  the  cervical  side,  if  the  aneurism 
be  of  the  subclavian.  In  aneurism  of  the  innominate,  further,  as  the 
tumor  is  under  the  right  sterno-articular  articulation,  percussion  does 
not  detect  any  distinct  enlargement  of  the  arch  of  the  aorta. 

An  aneurism  of  the  pulmonary  artery  is  a  rare  disease.  Its  main 
phenomena  are :  a  strongly  pulsating  swelling,  perceptible  to  the  left 
of  the  sternum,  and  limited  to  the  second  intercostal  space ;  a  marked 
thrill  with  each  expansion  of  the  aneurism ;  and  in  some  instances  a 
rough  murmur,  which  is  not  discovered  at  the  notch  of  the  sternum 
or  above  the  clavicles  ;  lividity  of  the  face  ;  dropsy  ;  great  difficulty  of 
breathing;  and  the  absence  of  obvious  evidences  of  pressure.^  The 
situation,  too,  of  the  physical  signs  is  important ;  yet  an  aneurism  of 
the  arch  may  occasion  a  pulsating  tumor  mainly  to  the  left  of  the  ster- 
num, and  may  even  break  into  the  pulmonary  artery.  A  mere  distinct 
beating  of  the  pulmonary  artery  is  discriminated  from  an  aneurism  of 
this  vessel  by  the  non-existence  of  a  palpable  swelling,  of  dropsy,  of 
embarrassed  breathing,  of  lividity  of  the  face,  and  by  the  usually  co- 
existing signs  of  some  consolidation  of  the  left  lung. 

Occasionally  we  meet  under  the  outer  half  of  the  left  cla^dcle  mth 
a  pulsating  tumor  presenting  thrill  and  murmur,  and  dilated  veins 
above.  The  signs  often  suddenly  disappear.  These  "mimic"  or 
phantom  aneurisms  *  are  apt  to  come  back  after  excitement  and  after 
movement  of  the  arms.  They  are  thought  to  be  due  to  temporary  dila- 
tation of  the  artery  from  vasomotor  paralysis,  Hmited  to  a  large  vessel 
or  to  part  of  it. 

^  Dublin  Quarterly  Journal,  vol.  xii. 
^  Holmes's  Surgery,  vol.  iii.  p.  562. 

^  In  the  •  case  detailed  by  Skoda,  Auscultation  and  Percussion,  the  dropsy  was 
great,  and  the  face  cyanotic  ;  there  was  no  murmur  over  the  pulmonary  artery. 
*  See  paper  by  Samuel  West,  St.  Barthol.  Hosp.  Rep.,  1880. 


CHAPTER   V. 

DISEASES   OF   THE   MOUTH,   PHARYNX,  AND   (ESOPHAGUS. 

The  diseases  of  this  part  of  the  digestive  system  need  not  here  be 
described  at  any  length,  because  many  of  them  have  been  already 
considered.     Yet  some  require  further  examination. 

MOUTH. 

Soreness  of  the  mouth,  pain  in  masticating,  and  a  fetid  breath  are 
often  complained  of  in  diseases  of  the  oral  cavity.  Let  us  suppose  a 
patient  to  present  himself  with  such  symptoms.  The  interior  of  the 
mouth  is  exposed  to  a  strong  light,  and  its  different  parts  are  inspected. 

The  gums  are  noticed  to  he  swollen  and  injected^  and  the  mucous  mem- 
brane lining  the  cheeks  reddened. — This  is  a  state  of  things  observed  in 
the  different  forms  of  stomatitis.  In  the  common  diffused  inflammation., 
the  result  of  direct  irritation,  such  as  the  swallowing  of  hot  liquids 
or  corrosive  substances,  or  an  accompaniment  and  consequence  of 
gastric  disorder,  the  redness  is  marked ;  any  attempt  at  chewing  is 
painful ;  the  taste  is  impaired ;  a  flow  of  saliva  takes  place  from  the 
mouth,  and  superficial  ulcerations  occur  at  its  various  parts,  hi 
mercurial  stomatitis  there  are  much  the  same  symptoms ;  but  the 
more  copious  discharge  of  saliva,  the  pain  in  the  jaws,  the  spongy 
gums,  the  loosening  of  the  teeth,  the  enlarged  tongue,  exhibiting  their 
impress,  the  painful  and  swollen  state  of  the  salivary  glands,  and  the 
peculiar  nauseous  breath,  testify  to  the  specific  character  of  the  inflam- 
mation. Ptyalism  may  be  accompanied  by  ulceration  of  the  lips  or 
cheeks,  and  followed  by  caries  or  necrosis  of  the  bones  of  the  jaw. 
The  sore  mouth  of  scurvy  is  distinguished  from  either  of  the  preceding 
forms  by  the  spongy,  purplish,  or  livid  gums,  which  bleed  on  the 
slightest  touch,  by  the  eruption  or  ecchymoses  on  the  skin,  and  by  the 
other  signs  which  attend  a  scorbutic  state. 

The  gums  and  the  inside  of  the  cheeks  and  lips  are  covered  with  a 
whitish  curd-like  exudation. — This  constitutes  the  form  of  stomatitis 
known  as  thrusJi.,  so  frequent  in  infants  at  the  breast,  and  so  con- 
stantly associated  with  intestinal  disorder,  with  diarrhoea,  with  colicky 
pains,  and  with  a  feverish  skin  and  a  hot,  dry  mouth.     Very  similar 

443 


444  MEDICAL   DIAGNOSIS. 

to  it,  regarded  indeed  by  some  as  identical,  is  the  aphthous  ulceration, 
to  which  adults  as  well  as  children  are  liable.  Here,  too,  a  whitish 
deposit  is  perceived  in  various  parts  of  the  mouth ;  it  is  apt  also  to 
be  combined  with  thirst  and  with  gastric  or  intestinal  disturbance, 
and  the  breath  has  a  very  disagreeable  odor.  The  recognized  differ- 
ence consists  in  the  presence  of  the  superficial  or  shahow  ulcers 
which  may  be  detected  when  the  white  crusts  that  cover  them  are 
removed,  and  the  vesicular  nature  of  the  disease  during  its  formative 
stage.  Then  more  or  less  redness  surrounds  each  spot,  the  ulcers 
are  slightly  raised  at  their  borders,  bleed  easily  on  pressure,  and  may 
be  irregular  from  several  running  together ;  their  grayish  covering  is 
soluble  in  ether,  and  presents  many  oil-globules  under  the  microscope. 
On  the  other  hand,  the  microscope  shows  us  in  thrush  a  special 
parasitic  formation,  the  oidium,  or  mycoderma,  albicans. 

Ulcerations  are  perceived  on  the  gums,  tongue,  and  various  parts  of 
the  mouth. — We  meet  with  ulcers  in  the  ordinary,  in  the  mercurial,  in 
the  scorbutic,  and  in  the  aphthous  inflammation  of  the  mouth.  They 
are  also  seen  attending  the  well-known  "  sore  mouth"  of  pregnant 
women,  and  accompanying  tuberculosis.  But  ulceration  is  apt  to 
exhibit  its  most  horrible  features  in  the  sore  mouth  of  syphilis,  and 
in  that  essentially  ulcerative  disease  called  cancrum  oris,  or  gangrenous 
stomatitis.  In  the  former  the  fauces  as  well  as  the  mouth  are,  as  a 
rule,  involved,  and  the  ulcers  show  peculiarities  which  we  shall 
presently  study.  The  latter  is  an  affection  which  prevails  especially 
in  enfeebled  constitutions.  It  is  seen  chiefly  in  hospitals,  and  not 
uncommonly  in  epidemics.  It  begins  with  pain  in  the  gums,  and 
these  soon  swell,  redden,  and  bleed  readily.  They  are  covered  with 
a  soft,  grayish  exudation,  which  often  extends  to  the  soft  palate.  If 
the  layer  of  exudation  be  scraped  away,  a  bleeding,  ulcerated  mucous 
membrane  comes  into  view.  The  breath  is  most  offensive  ;  a  profuse 
flow  of  saliva  is  noticeable ;  perforation  of  the  -cheek  quickly  takes 
place ;  the  bones  may  be  laid  bare,  the  teeth  loosened ;  there  is  usu- 
ally fever,  often  of  hectic  type  ;  yet  the  disease  does  not  uniformly 
progress  with  activity ;  it  may  last  for  weeks.  Tubercular  idceration 
is  distinguished  usually  by  a  chronic  course  and  by  the  presence  of 
tubercle  bacilli  in  the  granulations  and  in  the  submucous  tissues. 

The  tongue  is  red  and  swollen. — Changes  in  color  and  in  appearance 
of  the  tongue  occur  in  general  diseases  of  the  system,  and  more  es- 
pecially in  those  of  the  alimentary  canal.  The  tongue  is  also  more  or 
less  involved,  at  all  events  its  mucous  membrane  is,  in  the  different 
forms  of  stomatitis.  An  abnormal  state  of  the  covering  of  the  tongue  is, 
therefore,  far  from  being  a  sign  that  the  organ  itself  is  primarily  affected. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  CESOPHAGUS.    445 

Occasionally,  however,  we  do  meet  with  affections  of  its  deeper 
structures.  Its  nerves  may  be  the  seat  of  violent  neuralgia ;  its  mus- 
cles may  be  paralyzed ;  it  may  become  hypertrophied  or  cancerous ; 
it  may  undergo  progressive  atrophy  ;  or  it  may  be  in  a  state  of  acute 
inflammation.  The  latter  is,  perhaps,  the  most  frequent  of  its  mala- 
dies, and  is  readily  recognized  by  the  red,  swollen  look  of  the  organ, 
joined  to  a  burning  pain  in  it,  and  either  to  great  dryness  of  the  mouth 
or  to  constant  dribbling.  The  swelHng  usually  begins  at  the  anterior 
portion,  and  may  become  so  considerable  as  to  threaten  suffocation ; 
the  inflamed  tongue  fills  up  the  fauces  and  protrudes  out  of  the  mouth, 
and  the  unhappy  patient  can  neither  swallow  nor  utter  a  word.  He 
has  active  fever,  headache,  great  restlessness,  and  intense  thirst, — 
symptoms  which  last  for  several  days,  and  until  the  inflammation  sub- 
sides. This  may  run  on  to  suppuration  or  gangrene  ;  in  some  instances 
it  leaves  a  permanent  induration  that  may  be  mistaken  for  a  cancerous 
nodule.  Acute  glossitis  is  a  dangerous  complaint ;  fortunately,  it  is  a 
rare  one.  Its  most  frequent  cause,  as  now  seen,  is  direct  injury,  either 
from  wounds  or  the  stings  of  venomous  insects,  or  from  the  introduc- 
tion of  corrosive  substances  into  the  mouth.  Its  most  frequent  cause 
formerly  was  the  abuse  of  mercury  pushed  to  salivation.  At  times  it 
is  observed  as  a  complication  of  scarlatina  or  of  erysipelas. 

Other  affections  of  the  tongue  connected  with  diseases  of  its 
structure  have  been  mentioned  in  the  first  part  of  this  volume.  Cancer 
of  the  tongue  produces  the  greatest  alteration  in  the  form  and  texture 
of  the  organ.  Syphilis  of  the  tongue  gives  rise  to  deep  fissures,  ulcers, 
or  mucous  patches  and  gummous  nodules  which  may  be  difficult  to 
distinguish  from  cancer,  except  by  the  history  and  the  absence  of  pain. 
As  a  sign  of  recovery  from  syphilis,  the  tongue  may  present  a  peculiar 
indented  appearance;  similar  to  what  is  seen  in  the  syphilitic  liver, 

FAUCES. 

The  throat,  or  fauces, — that  is,  the  parts  at  the  back  of  the  mouth 
which  are  brought  into  view  when  the  lips  are  widely  opened,  such  as 
the  half-arches,  the  uvula,  the  tonsils,  the  posterior  wall  of  the  pharynx, 
— may  be  involved  in  the  same  diseases  as  the  parts  situated  in  front. 
The  contiguity  of  these  structures  is  in  fact  such  that  any  morbid  action 
is  apt  to  spread  to  them,  or  to  extend  from  them  either  forward  or 
downward  into  the  pharynx,  and  even  into  the  larynx.  The  most 
common  affections  of  the  fauces  are  inflammation  and  ulceration,  both 
of  which  occasion  a  feeling  of  uneasiness  in  the  throat,  and  also  diffi- 
culty or  pain  in  deglutition,  and  both  of  which  are  readily  enough 
detected  by  the  attendant  changes  in  color,  swelling,  or  exudation. 

28 


446  MEDICAL  DIAGNOSIS. 

In  the  ordinary  inflammation  of  the  fauces,  the  simple  angina^  or 
sore  throat,  the  parts  are  of  a  bright-red  color,  and  the  uvula  is  long 
and  swollen,  and  by  dropping  on  the  tongue  gives  rise  to  a  constant 
disposition  to  swallow,  although  the  act  of  swallowing  is  attended  with 
pain.  Associated  with  the  angina  are  coryza  and  febrile  disturbance  ; 
and,  owing  to  the  inflammation  travelling  up  the  Eustachian  tube,  the 
sense  of  hearing  is  impaired. 

Tonsillitis. — When  the  inflammation  penetrates  the  substance  of 
the  tonsils,  as  in  quinsy^  much  the  same  general  symptoms  occur  as  in 
ordinary  angina.  But  the  sense  of  constriction  in  the  throat  is  greater  ; 
so  is  the  difficulty  in  swallowing ;  and  liquids  are  apt  to  return  through 
the  nose.  The  voice  is  thick,  and  has  often  a  peculiar  sound ;  it  is 
painful  to  the  patient  to  talk,  and  on  looking  into  the  throat  the  tonsils 
may  be  seen  red,  prominent,  and  covered  with  mucus  which  is  not 
easily  detached.  Sometimes  the  swelling  is  so  considerable  that  the 
tumid  glands  fill  up  the  space  between  the  half-arches  and  leave  but 
a  smaU  interval  for  the  passage  of  food  or  drink.  The  lymphatic 
glands  at  the  angle  of  the  jaw  are  frequently  swollen.  Occasionally 
the  inflammation  extends  from  the  tonsils  -to  the  salivary  glands ;  the 
submaxillary  and  parotid  glands  swell,  and  ptyalism  takes  place. 
There  is  not  much  likelihood  of  confounding  this,  a  form  of  secondary 
parotitis^  with  mumps,  in  which  an  outward  swelling,  visible  beneath 
the  ear,  is  found,  but  not  a  swelling  within  the  throat,  and  in  which 
no  real  difficulty  in  swallowing  occurs,  except,  perhaps,  when  the 
tumefaction  is  at  its  height,  and  then  only  for  a  short  time. 

Tonsillitis  terminates  by  resolution  or  by  the  formation  of  pus. 
There  are  no  positive  means  of  ascertaining  that  the  inflammation  is 
going  to  end  in  suppuration,  although  we  may  suspect  that  this  will  be 
the  case  when  much  pain  is  felt  at  the  angles  of  the  jaws  and  shooting 
to  the  ear,  and  when  the  symptoms  have  been  severe  and  persistent 
for  more  than  four  or  five  days.  Sometimes  the  pus  may  be  seen 
through  the  covering  of  the  tonsils  ;  but  often  the  vast  sense  of  relief 
experienced  by  the  patient,  and  the  sudden  improvement  in  degluti- 
tion, attended,  perhaps,  with  an  unpleasant  taste,  are  the  only  signs 
that  the  collection  of  pus  has  been  discharged.  Attacks  of  tonsillitis 
are  prone  to  be  repeated,  and  may  lead  to  permanent  enlargement  and 
induration  of  the  tonsils.  The  enlarged  tonsils,  attended  as  they  fre- 
quently are  with  cervical  glandular  swellings,  may  be  mistaken  for 
cancer  of  the  tonsils.  But  in  this  affection  sanious  offensive  discharges 
from  the  mouth  occur,  and,  whether  the  disease  be  epithelioma  or 
round-cell  sarcoma,  it  extends  rapidly ;  the  neighboring  lymphatic 
glands  are  early  involved,  the  palate  and  the  pharynx  become  impli- 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  (ESOPHAGUS.    447 

cated,  and  hemorrhage  is  frequent,  as  are  also  difficulty  of  deglutition 
and  attacks  of  suffocation.^  Acute  tonsillitis  may  be  one  of  the  mani- 
festations of  the  rheumatic  poison,  and  become  associated  with  endo- 
carditis ;  ^  it  is  also  seen  in  connection  with  malaria.^  At  times  the 
tonsils  become  gangrenous.*  The  primary  lesion  of  syphilis  may  ap- 
pear on  the  tonsils  and  present  the  ordinary  sign  of  chancre, — ulcer- 
ation with  induration  of  surrounding  parts,  and  enlargement  of  neigh- 
boring lymphatic  glands,  all  yielding  rapidly  to  antisyphilitic  treatment. 

Acute  FoUioular  Tonsillitis. — There  is  a  form  of  acute  tonsillitis  that 
is  limited  to  the  folhcles  and  has  well-marked  clinical  features.  It 
begins  with  chilly  sensations,  to  which  a  moderate  fever,  rarely  ex- 
ceeding 103°,  succeeds.  After  a  few  days  the  fever  disappears,  a  slight 
evening  rise  remaining,  and  in  a  week  from  the  onset  the  patient  is 
quite  convalescent,  though  weak.  At  the  height  of  the  malady  a  swell- 
ing of  the  cervical  lymphatic  glands  is  often  observed.  But  the  char- 
acteristic feature  of  the  dise.ase  is  in  the  tonsils.  These  are  red  and 
slightly  tumefied,  and  a  thin  yellowish  or  whitish  punctiform  exuda- 
tion is  seen  in  the  crypts  and  around  the  follicular  openings.  This 
comes  away  gradually  ;  in  some  parts  much  sooner  than  in  others,  and 
for  days  after  convalescence  from  the  general  symptoms,  the  appear- 
ance is  found  in  some  follicles.  When  cast  off,  superficial  ulcerations 
on  the  glands  may  be  noticed.  This  form  of  tonsillitis  is  infectious, 
and  various  micro-organisms  have  been  found  in  the  exudate,  particu- 
larly streptococci,  staphylococci,  and  pyogenes  aureus  ;  also  the  pseudo- 
diphtheria  bacillus. 

Diphtheria. — There  is  another  affection  of  the  fauces  which,  in 
accordance  with  the  clinical  classification  followed  in  this  work,  may 
be  considered  here,  notwithstanding  its  specific  character, — mem- 
branous angina,  or  diphtheria.  Recent  research  leads  us,  indeed,  to 
believe  that  the  malady  is  primarily  a  local  one,  dependent  upon  the 
lodgement  and  multiplication  of  a  specific  bacterium.  The  constitu- 
tional symptoms  are  to  be  attributed  to  the  absorption  and  action  of 
the  toxic  products  generated  at  the  site  of  infection. 

The  bacillus  of  diphtheria  was  discovered  by  Klebs,  and  more  fully 
studied  by  Loeffler.  It  is  about  as  long  as  the  tubercle  bacillus,  but 
nearly  twice  as  thick.     It  is,  as  a  rule,  curved,  but  its  form  is  variable. 

1  Poland,  Brit,  and  For.  Med.-Chir.  Rev.,  April,  1872  ;  Newman,  Amer.  Journ. 
Med.  Sci.,  May,  1892. 

^  See  cases  reported  by  Frederick  A.  Pacliard,  Transactions  of  Association  of 
American  Physicians,  1899. 

3  Chassaignac,  N-ew  Orleans  Medical  and  Surgical  Journal,  Oct.  1888. 

^  Cragin,  New  York  Medical  Journal,  Sept.  1888. 


448  MEDICAL  DIAGNOSIS. 

It  has  rounded  extremities,  which  are  sometimes  club-shaped.  It  is 
non-motile  ;  it  does  not  form  spores.  It  may  be  stained  in  cover-glass 
preparations  with  Loeffler's  alkaline  methylene-blue  solution,  which 
consists  of  thirty  cubic  centimetres  of  a  concentrated  alcoholic  solution 
of  methylene-blue  and  one  hundred  cubic  centimetres  of  a  1 :  10,000 
solution  of  potassium  hydroxide.  The  organism  grows  best  upon  a 
culture-medium  consisting  of  three  parts  of  blood-serum  and  one  part 
of  a  mixture  of  meat-infusion  with  one  per  cent,  each  of  peptone  and 
grape-sugar  and  one-half  per  cent,  of  sodium  chloride.  This  is  steril- 
ized and  at  the  same  time  solidified  in  test-tubes  supported  at  an  acute 
angle  in  a  steam  or  hot-air  sterilizer  at  a  temperature  a  little  below 
100°  C.  The  inoculation  is  made  by  means  of  a  pledget  of  cotton 
wrapped  on  the  end  of  a  steel  rod,  and  the  culture-tube  is  kept  in  a 

Fict.  52. 
I.  II.  III. 

#1      *!      v^^ 


Klebs-LoefBer  bacilli,  from  specimens  prepared  by  Dr.  Coplin  and  Dr.  Bevan. 

Fig.  I.  Fresh  culture  upon  glycerin  agar-agar.    Eje-piecelV.,  Beck;  Objective  i^r  ol.  im.    Leitz. 
Fig.  n.  Fresh  culture  upon  blood-serum.    Ej-e-piece  IV.,  Beck;  Objective  jWoLim.    Leitz.    This 
is  also  the  appearance  when  obtained  directly  from  the  throat  and  subjected  to  the  same  power. 
Fig.  III.  Old  culture  upon  blood-serum.    Eye-piece  IV.,  Beck;  Objective  iV  ol.  im.    Leitz. 

thermostat  at  a  temperature  of  about  37°  C.  In  the  course  of  from 
twelve  to  twenty-four  hours  dense,  white,  opaque  colonies  develop, 
and  examination  of  cover-glass  preparations  will  disclose  the  presence 
of  the  characteristic  bacillus. 

Bacilli  resembling  true  diphtheria  bacilli  in  appearance  and  m  cul- 
ture, but  wanting  in  virulence,  have  been  described  as  pseudo-diph- 
theria bacilli ;  but  it  is  believed  that  these  are  merely  a  modified  form 
of  diphtheria  bacilli,  which,  as  Pasteur  demonstrated,  are  variable  in 
their  infectivity. 

The  disease  begins  usually  as  sore  throat,  with  redness  and  swell- 
ing of  the  arches  of  the  palate,  and  of  the  tonsils.  There  is  slight 
stiffness  of  the  neck,  the'  cervical  and  submaxillary  glands  of  the  jaw 
are  enlarged  and  tender,  and  the  subcutaneous  tissues  may  become 
involved  in  the  swelling.  Within  a  period  varying  from  a  few  hours 
to  a  few  days,  an  exudation  takes  place  on  the  tonsils,  the  uvula,  and 
the  soft  palate.     This  exudation  is*  more  or  less  extensive,  generally 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  CESOPHAGUS.    449 

tough,  and  of  a  white  or  grayish  hue.  It  may  show  but  Httle  ten- 
dency to  spread ;  or  it  may  extend  to  the  gums,  and  along  the  walls 
of  the  pharynx  into  the  windpipe,  sometimes  even  into  the  bron- 
chial tubes  and  the  lung  structure.  In  some  cases  it  passes  upward 
into  the  nares,  yet  it  may  begin  there  or  in  the  larynx  simultaneously 
with  its  appearance  in  the  throat.  It  usually  appears,  at  an  early 
stage,  as  a  thin  pellicle  on  the  soft  palate,  and  the  uvula  is  apt  to  be 
(Edematous. 

The  false  membrane  in  the  throat,  once  formed,  darkens,  wastes 
from  the  circumference  towards  the  centre,  and  gradually  disappears. 
But  sometimes  the  coat  becomes  for  a  time  thicker  and  thicker  by  the 
constant  addition  of  fresh  layers.  This  happens  particularly  in  the 
"  croupous  form"  of  diphtheria,  in  which  the  inflammation  is  more 
intense  from  the  onset  and  the  fibrinous  exudations  succeed  one 
another  rapidly  until  the  dense,  thick  coating  of  false  membrane  results. 
Under  any  circumstances,  when  artificially  removed,  the  pseudo-mem- 
brane is  soon  redeveloped.  After  the  first  week  from  its  beginning,  no 
further  exudation  is  apt  to  take  place,  and  the  danger  arising  from  the 
membrane  may  be  generally  looked  upon  as  over,  unless,  as  is  not  un- 
common, a  relapse  of  the  malady  occur.  The  specific  bacterium  may, 
however,  be  present  in  the  fauces,  nasal  passages,  and  maxillary  sinuses 
for  many  days,  even  for  weeks,  after  the  disease  has  apparently  come 
to  an  end.^  It  may  be  found  occasionally  when  there  is  no  false 
membrane,  and  also  in  the  throats  of  healthy  persons.^  The  Klebs- 
Loeffler  bacillus,  or  the  pseudo-diphtheritic  bacillus,  has  been  detected, 
too,  in  instances  presenting  all  the  features  of  follicular  tonsillitis,  and, 
however  valuable  a  sign,  it  is  still  an  open  question  whether  the  Klebs- 
Loeffler  bacillus,  in  the  absence  of  all  clinical  symptoms,  can  be  ac- 
cepted as  an  absolute  test  of  the  presence  of  diphtheria. 

The  constitutional  symptoms  vary  greatly.  The  pulse  may  be 
frequent,  the  skin  hot,  and  there  may  be  much  pain  in  the  head ;  in 
fact,  the  symptoms  are  those  of  fever,  with  a  temperature  of  102°  to 
103°.  Yet  the  temperature  is  exceedingly  variable ;  there  is  often, 
even  in  the  worst  cases,  an  almost  normal  temperature.  A  sense  of 
weakness  and  prostration  are  prominent  from  the  onset.     Not  rarely 

^  Abel  (Deutsche  Medicinische  Wochenschrift,  1894,  No.  35,  p.  692)  has 
recorded  a  case  in  which  virulent  diphtheria  bacilli  were  found  sixty-five  days  after 
the  onset  of  the  primary  illness  ;  also  Pearce  (Journ.  Boston  Soc.  Med.  Sci.,  March, 
1899). 

^  Feer,  Correspondenz-Blatt  fur  Schweitzer  Aerzte,  1893,  No.  8,  p.  295 ; 
Welch,  Amer.  Journ.  Med.  Sci.,  Oct.  1894,  p.  427  et  seq.  ;  Park  and  Beebe,  Medi- 
cal Record,  vol.  xlvi..  No.  1247,  p.  1. 


450  MEDICAL  DIAGNOSIS. 

the  urine  contains  albumin  and  casts,  and  there  may  be  partial  or 
complete  suppression  of  the  renal  secretion.  In-  some  instances 
typhoid  phenomena  manifest  themselves,  especially  when  decompo- 
sition of  the  disintegrating  exudation  takes  place,  giving  rise  to  the 
septic  form  of  the  malady  ;  in  this  the  temperature  may  be  even  below 
the  normal.  The  nervous  system  becomes  much  affected,  and  the 
tendon  reflexes  are  lost.^  In  children  exacerbations  of  pre-existing 
nervous  symptoms  may  take  place  and  give  rise  to  a  state  resembling 
acute  bulbar  palsy .^ 

In  diphtheria  the  danger  is  twofold :  it  arises  partly  from  the  de- 
pressing effect  of  the  poison,  increased  as  this  effect  must  be  by  the 
absorption  of  toxic  matter  from  the  throat,  partly  from  the  mechanical 
obstruction  caused  by  extension  of  the  disease  to  ■  the  larynx  and 
lungs.  Again,  at  the  height,  or  even  at  the  decline  of  the  malady, 
there  is  risk  of  heart-palsy  or  heart-clot,  and  of  peripheral  embolism.^ 
Nor  is  the  termination  of  the  acute  disorder  always  the  termination  of 
the  complaint.  A  chronic  irritation  of  the  throat,  lasting  weeks  or 
months,  and  readily  relapsing,  on  exposure  to  infection,  into  'a  diph- 
theritic sore  throat,  remains  ;  or  albuminuria,  which  outlasts  the  acute 
manifestations ;  or  pleurisy,  or  bronchitis  and  pneumonia, — both  of 
which  may  be  delayed  until  after  the  exudation  has  disappeared  from 
the  throat, — increase  the  list  of  the  complications  of  the  affection,  and 
protract  or  imperil  the  convalescence.  Occasionally,  too,  inflamma- 
tion of  the  joints  is  observed  in  the  course  of  diphtheria,  or  as  a  sequel, 
and  sometimes  trophic  changes  in  the  periarticular  structures  are  met 
with.* 

Some  morbid  conditions  there  are  which  may  be  wholly  looked 
upon  as  after-symptoms.  A  paralysis  of  the  velum  palati  and  of  the 
pharyngeal  arches,  making  itself  apparent  by  a  peculiar  nasal  intona- 
tion of  the  voice,  and  by  proneness  to  regurgitation  of  fluids  through 
the  nostrils,  is  among  the  earliest  of  them  ;  it  manifests  itself  often,  in- 
deed, just  at  the  termination  of  the  acute  malady.  Later  appear  im- 
pairment of  vision,  gastrodynia,  ulcers  in  various  parts  of  the  body, 
profound  anaemia,  and  that  gradual  failing  of  muscular  power  with 
anaesthesia,  and  absence  of  reflexes,  that  bespeaks  diphtheritic  paral- 

1  McDonnell,  Medical  News,  Oct.  15,  1887. 

^  Guthrie,  Lancet,  April  18,  25,  1891. 

^  A  case  has  been  recorded  in  which  embolic  obstruction  of  the  popliteal 
artery  occurred  during  convalescence  from  an  attack  of  diphtheria,  and  amputa- 
tion of  the  affected  member  became  necessary.  Rooney,  Occidental  Medical 
Times,  vol.  vii.,  No.  4,  p.  188. 

*  Lyonnet,  Lyon  Medical,  Jan.  4,  11,  1891. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  (ESOPHAGUS.    451 

ysis.  In  rare  instances  these  symptoms  occur  early  in  the  attack.^ 
They  are  attributable  to  the  development  of  a  peripheral  neuritis 
dependent  upon  the  action  of  the  toxic  products  of  the  disease. 
Hemiplegia  has  been  observed  in  some  cases  as  a  result  of  rupture  of 
a  cerebral  blood-vessel  or  its  occlusion  by  a  clot.^  Other  symptoms 
of  profound  nervous  derangement  have  also  been  recorded,  such  as 
peripheral  neuritis  in  which  the  sense  of  smell  and  the  muscular  sense 
were  lost  and  profound  impressions  were  referred  to  corresponding 
points  on  the  opposite  side  of  the  body,^  or  with  temporary  absolute 
deafness,  unsteadiness  of  gait,  and  paralysis  of  the  palate.*  Further- 
more, I  have  known  aphasia  to  follow  the  depressing  complaint. 

But  to  look  at  the  differential  diagnosis  of  the  disorder.  It  varies 
widely  from  stomatitis,  from  tonsillitis,  from  pharyngitis, — in  truth, 
from  all  the  ordinary  local  inflammations  of  these  structures, — by  the 
presence  of  a  membrane,  by  the  striking  constitutional  symptoms,  and 
by  the  sequelae.  The  diagnosis  becomes  unec{uivocal  if,  in  addition  to 
these,  the  characteristic  bacilli  are  found  on  bacteriologic  examination 
of  some  of  the  material  taken  from  the  throat  or  the  nose. 

Yet  there  are  certain  sources  of  error  against  which  it  is  necessary 
to  guard.  In  simple  pha7yngitis^  a  mass  of  mucus,  in  part  derived 
from  the  nares,  is  apt  to  collect  on  the  inflamed  membrane,  and  looks 
at  first  sight  like  the  coating  from  an  exudation ;  but  it  may  be  easily 
removed,  and  a  closer  inspection  proves  its  true  nature.  In  follicular 
tonsillitis,  liquid  may  ooze  from  the  openings  of  the  follicles  on  the 
surface  of  the  swollen  tonsils,  or  little  yellowish  or  whitish  points  form 
there. .  But  they  are  strictly  confined  to  the  gland,  exhibit  no  tendency 
to  spread  or  to  coalesce,  and  are  generally  small  white  specks  of 
roundish  or  oval  shape.  These  appearances  constantly  occasion  mis- 
takes, especially  as  regards  mild  cases  of  diphtheria.  '  What  adds  to 
the  difficulty  is  that  follicular  tonsillitis  is  contagious.  Should,  in  an 
individual  instance,  the  facts  mentioned  be  insufficient  to  solve  the 
doubt,  the  microscope  can  do  so  ;  for  it  shows  the  white  or  yellowish 
masses  to  be  largely  composed  of  epithelium,  with  streptococci  and 
staphylococci  in  abundance,  but  not  with  the  true  Klebs-Loeffler 
bacillus. 

^  As  in  two  cases  reported  by  Dabney,  Medical  News,  Jan.  16,  1892,  in  which' 
they  appeared  on  the  first  and  second  days  respectively. 

^  McPhedran,  Canadian  Practitioner,  1892,  No.  19,  p.  454  j  Allen  A.  Jones, 
Medical  News,  Oct.  22,  1892,  p.  467  ;  Edgren,  Deutsche  Medicinische  Wochenschrift, 
1893,  No.  36,  p.  864;  C.  W.  Sharpies,  Medical  News,  Aug.  4,  1894,  p.  124. 

^  Gay,  Brain,  part  Ixiii.  p.  431. 

*  Tooth,  BriUsh  Medical  Journal,  1893,  No.  1680. 


452  MEDICAL  DIAGNOSIS. 

Ulcerative  stomatitis,  the  form  of  stomatitis  most  likely  to  be  con- 
founded with  diphtheria,  and  especially  with  this  malady  when  the 
exudation  lines  the  gums,  is  discriminated  by  the  ulceration  or  slough- 
ing ;  whereas  the  mucous  membrane  in  the  pseudo-membranous  dis- 
ease remains  intact,  save  in  the  rarest  instances.  The  same  feature 
distinguishes  diphtheria  from  gangrene  of  the  mouth,  for  which,  on 
account  of  the  extreme  fetor  of  the  breath,  it  is  sometimes  mistaken, 
and  aids  in  distinguishing  it  also  from  other  kinds  of  stomatitis,  as 
from  thrush.  In  the  latter,  too,  the  buccal  mucous  membrane,  and 
not  the  throat,  is  chiefly  affected,  and  the  abdominal  symptoms,  and 
the  other  constitutional  phenomena,  are  different.  So  are  they  in 
ajjhthce,  in  which,  moreover,  the  superficial  ulcerations,  which  bleed 
when  touched,  the  unbroken  vesicles  or  pustules  in  other  parts,  and 
the  seat  of  the  disorder — usually  on  the  edge  of  the  tongue,  on  the 
internal  surface  of  the  lips,  and  on  the  gums  and  inside  of  the  cheek 
— are  points  to  be  taken  into  account. 

Besides  these  affections,  there  are  others  which  must  be  distin- 
guished from  diphtheria.  We  occasionally  find  cases  occurring  in  epi- 
demics, and  where  the  membrane  is  limited  nearly  altogether  to  the 
follicles,  and  chiefly  to  the  tonsils.  As  the  membrane  passes  away, 
ulcerations  are  obvious.  Swelling  of  the  glands  of  the  neck,  and 
fever,  but  not  of  acute  type,  attend  this  ulcero-membranous  angina, 
which,  moreover,  shows  a  strong  disposition  to  relapses.  But,  though 
kindred  to  diphtheria,  and  in  isolated  instances  perhaps  difficult  to 
discriminate,  it  differs  from  it  in  its  seat  and  in  its  want  of  tendency 
to  spread,  in  the  formation  of  superficial  ulcers,  in  its  less  marked  con- 
stitutional depression,  and  in  its  invariably  favorable  termination.^  It  is 
similar  to  herpes  of  the  tonsils,  described  by  Trousseau.  In  acute  in- 
flammation of  the  fauces  it  is  not  unusual,  especially  in  certain  families, 
to  find  a  form  of  exudation  on  the  surface  of  the  throat  due  to  excessive 
desquamation  of  the  superficial  layer  of  the  epithelium  of  the  inflamed 
mucous  membrane.  But  a  light  rubbing  with  a  cotton  tampon  re- 
moves it,  and  shows  a  surface  of  mucous  membrane  which  is  not 
bleeding  or  ulcerated.  The  false  membraiie  of  diphtheria  is  so  ad- 
herent to  the  subjacent  tissue  that  it  cannot  be  wiped  off,  and,  if 
removed  forcibly,  will  leave  a  bleedmg  surface  and  soon  be  repro- 
duced. Then,  as  already  stated,  there  are  cases  of  membranous,  or 
ulcerated,  sore  throat  with  membranes  that  are  not  diphtheritic,  in 
which  the  Loeffler  bacillus  is  absent,  and  various  forms  of  strepto- 

^  See  a  paper  in  the  Amer.  Journ.  Med.  Sci.,  July,  1870,  in  which  I  have  de- 
scribed an  epidemic  of  the  kind.  » 


DISEASES  OF  THE  MOUTH,  PHABYNX,  AND  (ESOPHAGUS.    453 

cocci,  staphylococci,  and  pseudo-diphtheritic  baciUi  are  found  in  the 
membrane,  as  in  instances  observed  among  soldiers  by  Cassedebat.^ 
Energetic  treatment  should  be,  however,  promptly  instituted,  since 
these  common  false  membranes  may  insidiously  prepare  the  way  for 
the  culture  of  the  diphtheria  microbe.  They  also,  by  entering  the 
crypts  of  the  tonsils,  may  lead  to  the  frequent  recurrence  of  this  form 
of  sore  throat.  In  the  appearance  of  the  false  membrane  there  is 
nothing  clinically  distinctive.  Whether  there  be  not  still  other  kmds 
of  membranous  sore  throat  to  be  separated  from  true  diphtheria  is  a 
matter  requiring  investigation.  The  pseudo-membranous  inflamma- 
tions of  the  throat  attending  scarlatina  and  measles  and  other  of  the 
exanthemata  have  been  shown  not  to  be  diphtheritic,  although  they 
seem  to  predispose  to  invasion  by  the  diphtheria  bacillus.^ 

There  is  an  acute  disease  of  the  throat  to  which  Todd  especially 
has  called  attention,^  and  which  presents  also  some  strong  points  of 
similitude  to  diphtheria, — erysipelas  of  the  fauces.  Like  diphtheria,  it 
is  a  most  dangerous  aOment;  as  in  diphtheria,  the  morbid  process 
may  extend  to  the  larynx,  the  mucous  membrane  be  swollen  and 
exhibit  a  peculiar  dusky-red  color,  the  poison  paralyze  the  muscles  of 
the  palate  and  pharynx,  and  liquids  be  rejected  through  the  nostrils 
and  mouth.  But  the  difficulty  in  deglutition  differs  from  that  of  diph- 
theria in  being  present  from  the  onset,  and  is  not  attended  with 
enlargement  of  the  glands  of  the  neck,  or  with  the  formation  of  a 
false  membrane.  If  the  erysipelatous  inflammation  extend  to  the 
larynx,  there  is  local  pain,  with  urgent  dyspnoea  and  hoarseness,  and 
usually  rapid  exhaustion  supervenes.  In  cases  of  the  kind,  the  sub- 
mucous tissues  of  the  larynx  are  found  extensively  infiltrated  with  pus. 
Erysipelas  of  the  fauces  may  happen  without  erysipelas  showing  itself 
on  any  external  part  of  the  body ;  on  the  other  hand,  erj^sipelas  be- 
ginning in  the  fauces  may  spread  to  the  face.* 

This  erysipelas  of  the  fauces  is  not  a  frequent  disease  ;  and  it  must 
be  stated  that  there  are  cases  of  diphtheria  which  simulate  it  very 
closely.  I  have  seen  a  number  of  instances  of  the  malady  m  which 
the  whole  mucous  membrane  was  of  a  vivid  or  dusky  hue  ;  in  which 
there  was  much  swelling,  with  an  effusion  of  serum,  especially  in  the 
submucous  tissue  of  the  iivula,  causing  it  to  look  like  a  small  trans- 

^  Des  Angines  Couenneuses  non  Diphtheriques,  Arch.  Gen.  de  Med..  1897,  p. 
385. 

^  Booker,  Bulletin  of  the  Johns  Hopkins  Hospital,  vol.  ill..  No.  26,  p.  129  ; 
Park  and  Beebe,  Medical  Record,  vol.  xlvi..  No.  1247,  p.  1. 

*  Clinical  Lectures  on  Acute  Diseases. 

*  Cases  quoted  in  Schmidt's  Jahrbiicher,  1869,  No.  1. 


454  MEDICAL  DIAGNOSIS. 

parent  bag ;  in  which  immense  difficulty  or  even  impossibility  in 
deglutition  existed, — ^yet  in  which  no  membrane  appeared  for  days 
after  the  violent  inflammation  of  the  throat  had  set  in,  and  was,  when 
it  showed  itself,  very  slight  in  extent,  and  out  of  all  proportion  to  the 
inflammation.  But  the  constitutional  symptoms  and  the  sequelae  were 
the  same  as  those  of  ordinary  diphtheria.  In  one  of  the  cases  of  the 
kind  referred  to,  suppuration  of  one  of  the  tonsils  took  place  in  con- 
sequence of  the  inflammation ;  a  layer  of  deposit  had  coated  parts  of 
the  tonsils  and  of  the  half-arches  and  uvula. 

How  shall  we  separate  diphtheria  from  membranous  croup  ?  In 
the  great  majority  of  instances  there  is  no  separation,  for  membranous - 
croup  is  laryngeal  diphtheria.  But  there  may  be  a  membranous 
croup  that  is  not ;  such  as  follows  scalding  the  throat,  irritant  poisons, 
violent  laryngitis,  or  is  seen  at  times  in  the  exanthemata.  Now,  in  cases 
of  non-diphtheritic  membranous  croup,  the  disease  affects  almost  al- 
ways primarily  the  windpipe.  The  reverse  is  the  rule  in  laryngeal 
diphtheria:  it  extends  from  the  throat.  Further,  ordinary  membra- 
nous croup  is  not  contagious,  as  diphtheria  is.  The  finding  of  the 
specific  bacillus  m  the  false  membrane  in  a  doubtful  case  establishes 
the  diagnosis. 

On  one  symptom  we  cannot  lay  as  much  stress  as  might  be  sup- 
posed. Albuminuria,  the  elaborate  report  of  the  committee  of  the 
Medico-Chirurgical  Society  has  taught  us,^  is  not  always  present  in 
laryngeal  diphtheria,  owing  to  the  early  fatality  of  the  malady ;  again, 
in  certain  cases  the  mere  dyspnoea  of  laryngitis  may  give  rise  to  albu- 
min in  the  urine.  Yet  when  albuminuria  is  marked,  and  when  it  has 
happened  where  an  affection  of  the  fauces  has  preceded  the  laryngeal 
implication,  it  points  to  an  infective  cause, — to  laryngeal  chphtheria. 

Lastly,  chphtheria  may  be  confounded  with  scarlatina.  When, 
indeed,  we  reflect  on  the  similar  appearance  of  the  throat,  on  the 
occurrence  of  albuminuria  in  both  maladies,  and  on  the  frequency 
with  which  both  are  found  to  prevail  at  the  same  time  as  epidemics  in 
a  community,  it  is  not  astonishing  that  one  should  be  looked  upon  as 
but  a  modified  form  of  the  other.  Allied  they  certainly  are,  but  not 
identical ;  for  the  poison  of  one  leads  to  a  thoroughly  defined  rash, 
and  leaves  a  protective  influence  against  a  second  attack,  and  often 
also  deafness,  suppuration  of  the  glands  of  the  neck,  and  dropsy, — 
phenomena  which  are  not-  encountered  in  the  other.  It  is  true  that 
in  very  rare  instances  of  diphtheria  we  encounter  a  slight  erythema 

^Medico-Chirurgical  Transactions,  vol.  Ixii.,  1879.  Some  of  the  anatomical 
points  involved  are  also  well  discussed  by  Weigert  in  Yirchow's  Arehiv,  vols.  Ixx. 
and  Ixxi. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  CESOPHAGUS.    455 

of  the  neck  and  breast,  but  it  is  not  like  the  vivid,  diffused  rash  of 
scarlet  fever.  Moreover  the  exudation  in  the  throat  is  not  exactly 
similar  in  the  two  diseases.  In  scarlatina  it  is  pultaceous,  and  not 
coherent,  and  has  no  tendency  to  spread  to  the  respiratory  passages. 
Bacteriologic  examination,  further,  may  disclose  the  presence  of 
streptococci  and  staphylococci,  but  not  the  bacillus  peculiar  to  diph- 
theria. Then  the  albuminuria  happens  at  a  different  period.  In 
scarlatina  it  is  a  sequel  rather  than  a  concomitant ;  in  diphtheria  it 
is  a  concomitant  rather  than  a  sequel.  Further,  the  gravity  of  the 
symptom  is  not  the  same.  In  the  latter  malady  it  is  an  indication  of 
danger ;  it  has  not  so  serious  a  meaning  in  the  former. 

Diphtheria  may  be  intercurrent  in  various  maladies :  in  typhoid 
fever,  in  the  exanthemata,  in  pneumonia.  A  microscopic  examination 
and  culture  experiments  can  alone  settle  whether  the  membranes  are 
truly  diphtheritic  or  only  formations  of  false  membranes.  The  exu- 
dation in  diphtheria  is  not  always  restricted  to  the  throat.  It  may 
show  itself  in  a  wound  or  on  excoriated  skin,  on  the  nasal  mucous 
membrane,  the  conjunctiva,  the  nipple,  the  uvula,  or  around  the  anus  ; 
it  may  be  found  coating  the  stomach,  the  intestines,  and  the  ramifica- 
tions of  the  bronchial  tubes. 

Nasal  dijMheria  is  a  very  grave  form  of  the  malady :  it  may  either 
be  present  alone,  or  coexist  with  a  deposit  in  the  fauces  and  pharynx. 
It  generally  occurs  with  evidences  of  the  septic  form  ;  the  symptoms 
are  of  a  low  type,  and  we  recognize  the  affection  by  carefully  inspect- 
ing the  posterior  pharynx  and  seeing  that  the  membrane  extends 
upward ;  by  noting  the  irritated,  reddened  look  of  the  nostril,  even 
when  no  membrane  can  be  discerned  in  it ;  and  by  the  coryza,  the 
sense  of  obstruction  in  the  nose,  and  the  acrid  sanious  discharge 
which  comes  from  it.  In  cases  in  which  the  nasal  duct  and  the 
lachrymal  canal  are  stopped  up  by  the  false  membrane,  tears  are  con- 
stantly rolling  down  the  cheeks.  Epistaxis  is  a  not  uncommon  symp- 
tom ;  swelling  of  the  cervical  glands  may  dr  may  not  be  present. 
Recent  bacteriologic  investigation  has  shown  that  so-called  mem- 
branous rhinitis  is  in  reality  often  of  diphtheritic  origin.^  And  in  the 
enlarged  glands  in  any  form  of  diphtheria  the  characteristic  bacilli  are 
found  in  the  opaque,  yellowish  masses,  consisting  principally  of  fibrin, 
which  they  contain.^ 

Mumps. — -This,  like  diphtheria,  is  a  general  disease,  and  is  only 
here  described  as  a  matter  of  clinical  convenience.     Parotitis  is  most 


1  Abbott,  Medical  News,  May  13,  1893,  p.  505. 

^  Bulloch  und  Schmorl,  Beitr.  zur  Pathol.  Anatomie,  etc.,  von  Ziegler,  B.  xvi. 
H.  2  ;  Centralblatt  fur  Innere  Medicin,  1895,  No.  6,  p.  156. 


456  MEDICAL  DIAGNOSIS. 

commonly  seen  as  an  epidemic  malady  ;  but  we  occasionally  encounter 
a  secondary  parotitis  following  typhus  fever,  scarlet  fever,  smallpox, 
measles,  and  dysentery.  In  this  form  suppuration  is  much  more  com- 
mon than  in  ordinary  mumps.  The  disease  generally  begins  with 
pains  at  the  angle  of  the  jaw,  which  are  soon  followed  by  a  marked 
swelling,  first  on  one  side,  then  on  the  other,  that  results  in  the 
head  being  kept  rigid.  The  tumid  glands  are  sore,  and  become  more 
painful  during  attempts  at  swallowing  and  chewing,  though  there  is 
really  little,  if  any  difficulty  in  swallowing.  If  the  patient  be  made  to 
swallow  slowly  ten  to  thirty  drops  of  undiluted  vinegar,  decided  pain 
is  produced  in  the  affected  glands, — an  old  and  useful  diagnostic  test, 
to  which  Dr.  Louis  Starr  called  my  attention.  The  mouth  is  gener- 
ally filled  with  saliva,  though  it  may  be  very  dry ;  and  the  hearing 
may  be  impaired,  or,  for  the  time  being,  entirely  lost,  and  ringing  in 
the  ears  is  very  common.  The  temperature  generally  ranges  between 
101°  and  102°,  but  in  cases  of  orchitis  following  mumps,  or  of  metas- 
tasis, I  have  seen  it  104°  to  105°.  The  nervous  system  may  become 
decidedly  affected,  and  the  action  of  the  heart  weak  and  irregular. 
Acute  mania  has  been  known  to  become  associated  with  mumps  ;  so 
has  peripheral  neuritis.^  Parotitis  is  easily  recognized.  There  is  no 
sweUing  of  the  tonsils,  hence  it  cannot  readily  be  mistaken  for  tonsil- 
litis. Laveran  and  Catrin  have  found  a  diplococcus  in  mumps,  in  the 
secretions  of  the  parotid  and  other  glands,  as  well  as  in  the  blood.^ 

In  cellulitis  of  the  neck,  angina  Ludoviei,  the  swelling  may  mis- 
lead, but  it  is  uniform  and  not  confined  to  the  region  of  the  parotids  ; 
the  constitutional  symptoms  are  very  severe,  pointing  to  an  infective 
malady.  Ludwig's  angina  is  met  with  as  an  idiopathic  affection,  or  in 
certain  fevers,  such  as  scarlet  fever  or  diphtheria. 

Chronic  Sore  Throat. — Attacks  of  angina  are  prone  to  recur,  and 
to  lead  to  chronic  inflammation  of  the  structures.  Now,  an  affection 
of  this  kind  is  liable,  on  any  exposure,  to  be  kindled  into  the  acute 
complaint ;  besides,  it  yields  at  all  times  some  manifestations  of  a  dis- 
order of  the  throat.  A  thickening  of  the  folds  of  membrane  formmg 
the  half-arches,  a  tumefaction  of  the  follicles  at  the  upper  part  of  the 
pharynx,  a  lengthening  of  the  uvula,  are  the  visible  signs  of  the  chronic 
malady ;  a  constant  disposition  to  clear  the  throat,  and  a  dry  cough, 
are  often  the  attending  general  symptoms.  Owing  to  the  habitual 
coughing,  the  patient  may.  be  suspected  to  be  laboring  under  phthisis, 
and  be  treated  accordingly,  when  the  whole  difficulty  lies  not  in  the 
lungs,  but  in  the  throat.     Yet  an  error  in  the  opposite  direction  is  per- 


^  Lancet,  April  9,  1887.  ^  Gazette  Medicale,  June,  1893. 


DISEASES   OF  THE  MOUTH,  PHARYNX,  AND  (ESOPHAGUS.    457 

haps  more  frequently  committed.  Tonsils  and  uvulas  are  removed, 
with  the  view  of  curing  a  cough  which  is  really  kept  up  by  a  source  of 
disturbance  in  the  lungs,  in  forgetfulness  of  the  fact  that,  in  scrofula, 
and  tuberculosis,  chronic  enlargement  of  the  tonsils  and  follicular 
pharyngitis  are  by  no  means  unusual.  A  careful  examination  of  the 
chest  and  a  bacteriological  examination  of  the  sputum  ought  always  to 
be  made,  even  when  inspection  of  the  throat  shows  disease  to  be  there 
present. 

The  follicular  disease  of  the  throaty  or  "  clergyman's  sore  throat,"  is 
the  most  frequent  of  all  the  morbid  conditions  which  produce  a  chronic 
sore  throat.  The  abnormal  condition  of  the  follicles  of  the  pharynx 
and  fauces  often  extends  to  the  larynx.  There  are  constant  hawking 
and  attempts  at  clearing  the  throat,  and  not  infrequently  roughness  of 
voice  or  decided  hoarseness.  On  inspecting  the  throat,  the  enlarged 
mucous  follicles  can  be  readily  discerned ;  those  on  the  pharynx  are 
very  prominent.  In  cases  of  long  standing,  the  follicles  may  ulcerate, 
and  very  commonly  they  pour  out  an  acrid  secretion.  But,  unless 
from  coexisting  enlargement  'of  the  uvula,  or  an  altered  position  of  the 
epiglottis,  or  a  laryngeal  or  bronchial  complication,  there  is  no  decided 
cough.  The  follicular  disease  may  occur  in  consequence  of  repeated 
attacks  of  sore  throat,  or  be  an  attendant  upon  gastric  disorder,  or 
follow  constant  over-exercise  and  straining  of  the  voice. 

Chronic  rheumatic  sore  throat  gives  rise  to  pain  which  is  often 
referred  to  the  hyoid  bone,  is  increased  by  pressure,  and  is  also  felt  in 
the  tonsils.  Ingals  ^  points  out  that  the  pain  often  entirely  disappears 
while  the  patient  is  eating,  but  increases  in  cloudy  and  damp  weather. 
There  are  signs  of  slight  congestion  in  the  throat,  and  generally  in  the 
larynx,  yet  mostly  out  of  all  proportion  to  the  pain.  The  general 
health  remains  good,  and  we  find  no  fever ;  there  is  apt  to  be  a  histoi"y 
of  a  rheumatic  diathesis. 

Ulcers  are  not  often  developed  in  the  fauces  during  an  attack  of 
acute  inflammation,  except  in  the  specific  sore  throat  of  scarlatina ;  in 
chronic  inflammation,  especially  if  occurring  in  scrofulous  persons, 
they  are  more  common.  The  most  profound  ulcerations  are  those  of 
constitutional  syphilis,  implicating,  as  they  do,  not  only  the  tissues  of 
the  fauces,  but  also  the  parts  in  front,  and  destroying  both  the  fleshy 
covering  of  the  bones  and  the  bones  themselves.  With  regard  to 
treatment  and  to  prognosis,  it  is  of  the  utmost  importance  to  distin- 
guish these  syphilitic  ulcers  from  those  produced  by  other  causes. 
The  coexistence  of  a  cutaneous  eruption  of  a  syphilitic  character,  and 


Medical  News,  March,  1890. 


458  MEDICAL   DIAGNOSIS. 

enlarged  lymphatic  glands,  or  the  history  of  antecedent  syphihs,  would 
lead  us  to  a  correct  conclusion ;  but  an  accurate  history  of  a  syphilitic 
infection  cannot  be  always  obtained.  The  ulcers  are  not  superficial 
and  stationary,  like  those  resulting  from  ordinary  inflammation,  but 
are  deep  and  have  a  strong  tendency  to  spread.  They  are  rounded, 
or  of  a  serpiginous  form,  with  borders  well  defined  and  elevated ;  and 
the  inflammation  which  precedes  them  is.  limited  to  spots,  and  is  not 
so  diffused,  nor  attended  with  so  much  swelling,  as  the  inflammation 
that  exists  prior  to  simple  ulceration.  The  primary  lesion  is  occa- 
sionally met  with,  cases  of  chancre  of  the  tonsil  being  wefl  known  to 
syphilographers.  Syphilitic  ulcers  must  be  distinguished  from  the 
deep  ulceration  with  spreading  destruction  of  tissue  that  occurs  in 
cancer  of  the  tonsils.^ 

PHARYNX  AND  (ESOPHAGUS. 
In  describing  the  affections  of  the  fauces,  those  of  that  portion  of 
the  pharynx  which  is  most  usually  the  seat  of  disease  have  been  at  the 
same  time  described.  Indeed,  when  we  speak  of  acute  or  chronic 
pharyngitis,  we  generally  mean  acute  or  chronic  inflammation  of  the 
fauces,  to  which  the  upper  part  of  the  pharynx  belongs.  Inflamma- 
tion of  the  portion  of  the  pharynx  which  is  out  of  sight  when  the 
tongue  is  depressed  is  rare.  It  may  be  presumed  to  exist  if  there  be 
pain  and  an  impediment  in  swallowing  when  the  food  arrives  opposite 
the  top  of  the  larynx,  while  the  respiration  remains  free  and  the  voice 
unaffected.  Abscesses  sometimes  form  between  the  textures  com- 
posing the  pharynx,  and  between  its  posterior  wall  and  the  cervical 
vertebrae.  These  retropharyngeal  abscesses  mostly  result  from  disease 
of  the  vertebrae.  They  occasion  great  difficulty  in  deglutition  and  in 
breathing ;  an  altered  voice ;  dull  pain  and  stiffness  in  the  neck ; 
external  swelhng,  which  may  or  may  not  be  (Edematous ;  and  com- 
monly a  tumefaction  at  the  back  of  the  throat,  which  can  be  seen,  or 
which  can  be  felt  with  the  finger  pressed  against  the  posterior  wall 
of  the  -pharynx.  On  account  of  the  obstructed  respiration  and  the 
changed  voice,  the  disease  is  liable  to  be  mistaken  for  croup.  Its  dif- 
ferences have  been  already  enumerated.  Retropharyngeal  abscess  is 
often  confounded  with  coryza  and  tonsillitis.  It  differs  chiefly  from 
tuberculosis  of  the  retropharyngeal  glands  by  the  presence  of  tuber- 
culous lesions  of  the  deep  lymphatic  glands  of  the  neck.^  It  may 
happen  in  infancy.^ 

^  See  Newman,  Amer.  Journ.  Med.  Sci.,  May,  1892. 

■'  Sokoloff,  Vratch,  May,  1891. 

^  See  cases  of  Pollard,  Lancet,  Feb.  1892. 


DISEASES  OF  THE  MOUTH,  PHAEYNX,  AND  (ESOPHAGUS.    459 

There  is  a  peculiar  form  of  pharyngeal  disease  due  to  the  accumu- 
lation on  the  mucous  membrane  of  a  micro-organism  generally  sup- 
posed to  be  the  leptothrix,  though  Hemenway  ^  in  his  elaborate  article 
pronounces  it  to  be  the  bacillus  fasciculatus.  The  deposits  in  this 
pharyngo-mycosis  take  place  largely  in  the  follicles. 

Oesophagus. — The  oesophagus  is  not  often  the  seat  of  disease.  We 
meet  with  acute  inflammation  produced  by  swallowing  boiling  water 
or  corrosive  poisons,  especially  nitric  or  sulphuric  acid,  or  ammonia. 
The  symptoms  of  acute  oesophagitis  are  usually  mixed  up  with  those  of 
inflammation  of  the  pharynx  or  of  the  stomach.  We  may,  however, 
infer  its  presence  if  difficulty  and  pain  in  deglutition  exist  for  which 
nothing  in  the  throat  accounts,  and  if  these  phenomena  be  asso- 
ciated with  hiccough  and  with  a  burning  sensation  between  the  shoul- 
ders, in  the  course  of  the  tube.  OEsophagitis  is  sometimes  encoun- 
tered in  infancy. 

Of  the  chronic  diseases  of  the  oesophagus,  stricture  is  the  most 
common.  The  narrowing  may  take  place  at  any  part  of  the  tube,  and 
results  from  preceding  inflammation  or  ulceration,  from  cancerous  de- 
generation of  the  walls,  from  polypoid  growths  projecting  from  the 
mucous  membrane,  or  from  the  pressure  of  a  tumor,  of  an  abscess,  or 
of  an  aneurism ;  sometimes  it  is  congenital.  The  formidable  malady 
manifests  itself  by  an  impediment  in  swallowing ;  even  liquid  food 
cannot  pass  without  great  difficulty ;  and  if  the  stricture  go  on  in- 
creasing, the  patient  perishes  miserably  by  starvation.  In  addition  to 
the  obstruction  to  the  passage  of  food,  we  may  find  a  peculiar  pain  oc- 
curring at  a  particular  part  of  the  tube,  and  the  patient  raises,  without 
cough  or  vomiting,  clots  of  blood  presenting  the  shape  of  the  stricture. 

The  matter  ejected  in  the  attempts  at  deglutition  consists  simply  of 
masticated  food  together  with  more  or  less  mucus,  and,  unlike  what 
comes  from  the  stomach,  has  an  alkaline  reaction.  If  long  retained, 
the  albuminous  materials  are  macerated  ;  the  starchy  materials  are  in 
process  of  fermentation  ;  fungi  are  formed  in  great  quantities,  although 
never  sarcinee.^  By  applying  the  stethoscope  posteriorly,  between  the 
shoulders  and  at  the  lower  part  of  the  neck,  while  the  patient  swallows 
a  mouthful  of  water,  a  peculiar  sound  is  heard  when  the  water  passes 
through  the  narrowed  portion  of  the  tube.  Should  there  be  doubt  as 
to  the  seat  of  the  obstruction,  a  bougie  will  clear  up  the  doubt ;  and  thus 
we  possess  in  this  instrument  the  most  valuable  diagnostic  as  well  as 
therapeutic  agent.     But  we  must  not  immediately  conclude,  because 

^  Journal  of  Laryngology,  Feb.  1892. 

^  Ziemssen,  "  Diseases  of  the  CEsophagus,"  in  Ziemssen's  Cyclopaedia. 


460  MEDICAL  DIAGNOSIS. 

the  bougie  meets  with  resistance,  that  an  organic  stricture  is  present. 
The  narro^ving  may  be  only  spasmodic.,  yet  give  rise  to  the  symptoms 
of  organic  constriction.  But  they  are  not  permanent :  at  times  nour- 
ishment is  readily  swallowed,  and  a  full-sized  bougie  passes  with  ease. 
Spasmodic  stricture  occasionally  accompanies  ulceration  of  the  larynx  ; 
but  it  is  chiefly  met  with  in  hypochondriacs  and  in  hysterical  women. 
The  latter,  indeed,  sometimes  fancy  that  they  are  incapable  of  swal- 
lomng,  and  reject  the  food  they  take  without  there  being  even  a 
temporary  spasm  to  prevent  its  passage.  Spasmodic  stricture  is  also 
observed  in  hydrophobia  and  as  an  attendant  on  cerebral  disease. 

The  distinction  of  the  other  causes  of  stricture  is  not  always  an 
easy  matter.  In  the  stenosis  arising  from  syphilis,  we  lay  great  stress 
on  the  history.  In  the  strictures  due  to  compression,  we  discern  the 
swelling  that  has  occasioned  them,  and  the  oesophagus  is  apt  to  be 
pushed  to  one  side.  In  strictures  the  result  of  cicatrices,  we  have  the 
gradual  development  of  the  affection  after  an  injury  or  the  swallowing 
of  some  irritant  poison,  and  the  great  resistance  of  the  dense  tissues 
to  the  sound  is  very  significant.  Cancerous  nai^roiving  occurs  after 
forty  years  of  age,  progresses  steadily,  and,  as  Ziemssen  has  pointed 
out,  is  frequently  associated  with  paralysis  of  the  recurrent  laryngeal 
nerves.  It  may  affect  the  whole  middle  part  of  the  oesophagus.^ 
Cancer  of  the  oesophagus  is  most  commonly  epithelioma.  We  may 
get  great  aid  in  the  study  of  these  organic  diseases  of  the  oesophagus 
from  the  X-rays.  They  will  also  show  us  readily  whether  a  foreign 
body  is  present,  or  whether  the  signs  of  obstruction  are  due  to  the 
pressure  of  an  aneurism. 

Rupture  of  the  oesophagus  may  be  met  with  as  the  result  of  pro- 
tracted vomitmg  or  the  introduction  of  bougies.  The  accident  is  apt 
to  occasion  great  pain.     It  leads  to  a  rapidly  fatal  result.^ 

Dilatation  of  the  oesophagus  above  the  seat  of  a  stricture,  or  with- 
out a  stricture  existing,  is,  on  the  whole,  a  rare  disease.  Its  chief 
symptoms  when  extensive,  are  difficulty  in  swallowing,  vomiting,  or 
regurgitation  of  food,  a  swelling  in  the  neck  coming  on  after  eating 
and  diminishing  greatly  after  vomiting  or  by  pressure,  slowly  pro- 
gressing inanition,  and  at  times  long  spells  of  delusive  improvement. 
The  sound  may  penetrate  through  the  neck  of  the  sac  with  difficulty, 
or  enter  it  readily,  which  largely  depends  upon  whether  the  sac  be 
empty  or  full ;  once  in  the  sac,  the  end  of  the  tube  can  be  generally 
moved  about  with  ease. 

^  Moore,  Lancet,  London,  1883,  i.  13. 

^  See  for  cases,  paper  by  Fitz,  Amer.  Journ.  Med.  Sci.,  Jan.  1877. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  (ESOPHAGUS.    461 

In  all  the  diseases  mentioned,  the  value  of  the  sound  as  a  means  of 
diagnosis  has  been  spoken  of.  A  few  more  remarks  about  it  may  not 
be  amiss.  Great  care  should  be  always  used  in  passing  a  sound.  The 
patient's  head  should  be  well  thrown  back,  and  the  instrument  passed 
along  the  posterior  wall  gf  the  pharynx  with  the  utmost  gentleness. 
There  is  a  slight  resistance  as  it  goes  past  the  cricoid  cartilage.  When 
an  aneurism  or  an  organic  disease  of  the  heart  exists,  it  should  not  be 
employed  at  all.  When  the  sound  on  reaching  a  particular  spot  al- 
ways occasions  pain,  we  may  infer  the  existence  of  inflammation  or 
ulceration  at  this  point,  and,  in  the  case  of  ulceration,  some  pus  or 
blood  is  likely  to  be  brought  up  on  the  instrument.  Should  any 
doubt  exist  whether  the  sound  has  passed  into  the  oesophagus  or  mto 
the  larynx,  let  the  patient  be  directed  to  speak ;  he  can  make  no  noise 
if  the  tube  be  in  the  larynx.  In  cases  remaining  doubtful,  a  lighted 
candle  may  be  placed  before  the  end  of  the  tube  projecting  from  the 
mouth.  If  the  instrument  be  in  the  windpipe,  the  flame  will  be 
wafted  to  and  fro  with  the  currents  of  air ;  if  in  the  esophagus,  this  is 
not  observed,  except  when  the  tube  is  in  the  intrathoracic  portion. 

The  diseases  of  the  oesophagus  may  be  studied  by  means  of  aus- 
cultation, listening  while  the  patient  swallows  food  or  liquid ;  and  we 
owe  to  Hamburger  an  elaborate  description  of  the  sounds.^  In  health, 
the  oesophageal  sound  is  extremely  distinct,  but  of  very  short  dura- 
tion ;  the  pharyngeal  swallowing  sound  is  generally  a  loud  gurgle. 
In  a  moderately  advanced  stage  of  stricture  of  the  cesophagus,  a  noise 
similar  to  emptying  a  bottle,  "clucking,"  "gurghng,"  is  perceived; 
while  in  cases  of  dilatation  we  are  apt  to  meet  with  a  sound  like  that 
heard  when  rain  driven  by  the  wind  impinges  on  a  solid  and  is  de- 
flected. In  cases  of  very  marked  stricture  or  of  obstruction  by  an 
impacted  foreign  body,  we  find  that  the  act  of  deglutition  cannot  be 
detected  below  a  certain  point,  while  it  is  distinct  above.  To  auscult 
the  oesophagus,  the  stethoscope  should  be  placed  in  the  vicinity  of  the 
hyoid  bone,  also  to  the  left  of  the  vertebral  column  from  the  upper 
dorsal  vertebra  downward.  This  method  of  exploration  has  not, 
however,  proved  itself  of  much  value.  Some  cases  show  that  the 
phonendoscope  is  of  greater  service. 

The  disorders  of  the  pharynx  and  oesophagus  have  as  a  common 
symptom  difficulty  in  swallowing'.  But  we  must  not  forget  that  other 
causes  may  produce  dysphagia,  such  as  paralysis  of  the  muscles  of  the 
throat,  diseases  of  the  larynx  or  trachea,  particularly  ulcerative  dis- 
eases, and  aneurismal  tumors  within  the  chest. 

^  Jahrbiicher  der  k.  k.  Gessellschaft  der  Aerzte  in  Wien,  Bd.  xviii. 

29 


CHAPTER   VI. 

DISEASES   OF   THE   ABDOMEN. 

The  abdominal  cavity  contains  viscera  of  very  varied  functions : 
some  form,  others  break  down  organic  constituents ;  while  others, 
again,  excrete  the  broken-down  material.  They  all,  however,  labor 
in  one  cause ;  they  all  work  towards  preserving  a  normal  state  of  the 
blood,  either  by  preparing  fit  matter  for  it  or  by  removing  such  sub- 
stances as  would  be  hurtful  if  they  were  retained.  Any  serious 
derangement  of  any  of  these  viscera,  especially  any  serious  chronic 
derangement  of  those  which  are  not  simply  reservoirs,  must  there- 
fore lead  to  a  deterioration  of  the  blood  and  to  a  defective  nourish- 
ment of  the  body.  But  these  symptoms  furnish  but  little  information 
as  to  the  particular  organ  at  fault.  This  we  learn  to  some  extent  by 
examining,  where  it  can  be  done,  the  secretions  or  excretions  ;  to 
some  extent  by  noticing  the  peculiar  appearances  of  the  skin  which 
are  produced  by  alteration  of  the  blood ;  and  by  the  exploration  of 
the  organs  through  the  parietes  of  the  abdomen.  It  is,  in  truth,  by 
means  of  the  physical  method  of  investigation  that  we  often  obtain  the 
most  valuable  information,  not  only  as  to  the  seat  but  even  as  to  the 
nature  of  the  morbid  action ;  and,  although  physical  exploration  of 
the  abdomen  does  not  yield  as  perfect  results  as  when  applied  to  the 
affections  of  the  thorax,  it  still  supplies  us  with  an  amount  of  knowl- 
edge most  valuable,  and  with  which  it  would  be  difficult  to  dispense. 
Let  us  pass  in  review  the  different  methods  of  physical  diagnosis  with 
reference  to  abdommal  disorders. 

Methods  and  General  Results  of  Physical  Examination  of 

the  Abdomen. 

INSPECTION. 
By  inspection  we  learn  the  size,  shape,  form,  and  movements  of 
the  abdomen.  To  inspect  the  abdomen  satisfactorily,  the  patient 
should  be  placed  in  an  easy  attitude,  preferably  either  standing  or 
sitting.  Whenever  practicable,  ocular  inspection  must  be  made  not 
only  from  the  front,  but  also  from  the  sides  and  from  the  back.     In 

462 


DISEASES  OF  THE  ABDOMEN.  463 

appreciating  the  results  thus  obtained,  it  is  necessary  to  bear  in  mind 
that  the  appearance  of  the  abdominal  walls  is  modified  by  certain 
physiological  conditions.  The  abdomen  is  much  larger,  in  comparison 
to  the  size  of  the  chest,  in  childhood  than  in  adult  age.  It  is  more 
voluminous  in  women,  especially  such  as  have  given  birth  to  children. 
It  increases  in  size  with  advancing  years,  particularly  when  a  tendency 
to  obesity  exists.  Its  shape  is  somewhat  altered  by  the  pernicious 
habit  of  wearing  tight  stays.  Its  upper  portion  is  distended  after  a 
copious  meal. 

In  disease  we  may  observe  either  partial  or  general  abdominal 
enlargement.  The  latter  is  caused  by  accumulations  of  air  in  the  in- 
testinal canal ;  by  liquid  in  the  peritoneum  ;  by  an  oedematous  or 
obese  condition  of  the  abdominal  walls  ;  or  by  large  tumors  which  fill 
up  the  whole  cavity.  A  partial  enlargement  is  mainly  produced  by 
an  increase  in  size  of  particular  organs,  or  by  swelling  of  the  mesen- 
teric glands,  or  by  tumor, — solid  or  hernial ;  and  it  is  sometimes  due 
to  diseases  above  the  diaphragm.  A  pleuritic  or  a  pericardial  effu- 
sion, or  emphysema  of  the  lungs,  may  give  rise  to  a  marked  fulness 
below  the  margin  of  the  ribs.  The  condition  known  as  enter oj^tosis^ 
or  splanchnoptosis.,  in  which  there  is  undue  freedom  of  movement  of 
the  abdominal  viscera,  may  reveal  itself  to  inspection  by  the  flaccidity 
and  thinness  of  the  abdominal  parietes  and  their  protrusion  in  the 
upright  posture.  Sometimes,  also,  the  outlines  of  the  viscera  may  be 
distinguishable. 

A  retraction  of  the  abdominal  parietes  is  perceived  in  general  emaci- 
ation, and  is  very  obvious  in  that  dependent  upon  a  narrowing  of  the 
cardiac  or  the  pyloric  orifice  of  the  stomach,  or  upon  chronic  diarrhoea 
or  dysentery.  It  is  also  noticed  in  lead  colic  and  in  cephaHc  diseases, 
especially  in  tubercular  meningitis. 

There  are  further  changes  in  the  appearance  of  certain  external 
parts  which  tend  to  elucidate  the  state  of  the  parts  within.  Distention 
of  the  superficial  veins  indicates  that  an  obstruction  to  the  flow  of 
blood  exists  in  the  large  veins  of  the  abdomen,  either  in  the  portal 
system  or  in  the  vena  cava.  The  lessening  of  the  depression  at  the 
umbilicus,  unless  it  be  produced  by  pressure  limited  to  the  spot  where 
the  umbilicus  lies,  is  a  sign  of  general  abdominal  enlargement. 

While  inspecting  the  abdomen,  we  may  see  distinct  movements. 
The  act  of  breathing  gives  ftse  to  motion  which  is  very  slight  when  a 
tumor  or  any  other  impediment  interferes  with  the  free  action  of  the 
diaphragm,  and  which  is  much  exaggerated  by  diseases  within  the 
thoracic  cavity.  The  rolling  of  the  intestines  is  sometimes  visible  on 
the  exterior ;  so  are  at  times  those  shiftings  of  accumulations  of  gas 


464  MEDICAL  DIAGNOSIS. 

which  give  rise  to  a  series  of  jerking  elevations ;  so,  too,  are  occa- 
sionally the  spasmodic  contractions  and  relaxations  of  the  abdominal 
muscles.  But  none  "of  these  is  as  frequently  encountered  as  a  pulsa- 
tion in  the  epigastric  region.  The  inspection  of  internal  organs,  such 
as  the  stomach,  will  be  considered  in  connection  with  those  organs, 

PALPATION. 

We  judge  by  the  application  of  the  hand  of  the  size,  position,  and 
consistence  of  the  viscera  which  are  felt  through  the  abdominal  walls. 
We  determine  whether  the  parts  are  firmly  attached  or  movable ; 
whether  they  are  smooth  or  nodulated ;  whether  they  possess  a 
motion  of  their  own  ;  whether  they  are  tender ;  and  by  tapping  with 
the  fingers  of  one  hand,  while  those  of  the  other  are  applied  to 
another  portion  of  the  surface,  we  discover,  by  the  peculiar  feeling  of 
fluctuation,  the  presence  of  fluid  in  the  abdominal  cavity.  We  satisfy 
ourselves  further,  by  the  sense  of  touch,  of  the  existence  and  outlines 
of  abdominal  tumors,  and  of  the  state  of  the  parietes,  whether  resistant 
or  elastic,  (Edematous  or  not ;  and  we  may  detect  a  friction  fremitus. 

In  order  to  use  palpation  with  most  efl'ect,  the  abdominal  muscles 
must  be  relaxed ;  and  to  do  this  the  patient  should  be  placed  on  his 
back,  and  the  thighs  be  flexed  on  the  body.  Occasionally  it  is  essen- 
tial to  vary  this  position  ;  to  turn  him  from  side  to  side,  or  to  examine 
him  when  erect.  The  amount  of  pressure,  too,  should  not  always 
be  the  same.  When  we  wish  to  examine  deep  parts,  the  pressure  is 
increased.  The  character  and  the  intensity  of  the  pain  that  pressure 
calls  forth  often  throw  considerable  light  on  the  disease  we  are  in- 
vestigating. Thus,  if  it  take  deep  pressure  to  produce  pain,  we  are 
usually  right  in  concluding  that  the  mischief  is  not  superficially  seated. 
The  pain  of  inflammation  of  the  serous  membrane  is  commonly 
much  augmented  by  pressure,  and  is  of  a  severe,  cutting  character. 
Pain  due  to  inflammation  of  the  mucous  membrane  of  the  intestinal 
tract  is  duller.  All  neuralgic  or  nervous  pain,  such  as  that  of  colic, 
is,  as  a  rule,  relieved  rather  than  increased  by  pressure,  and  may  be 
thus  distinguished  from  inflammatory  tenderness.  One  or  both  hands 
may  be  used  in  the  practice  of  palpation,  and  sometimes  shock-like 
manipulations  mil  reveal  conditions  not  otherwise  discoverable. 

Palpation  is  used  as  a  means  of  diagnosis  by  the  introduction  of 
the  hand  into  the  rectum.  But  the  method  is  both  disagreeable  and 
not  free  from  danger.  Dilatation  of  the  sphincter  should  be  gradual, 
five  minutes  at  least  being  allowed  for  its  accomphshment.  And,  with 
all  precautions,  the  information  obtained  may  be  indecisive.  Strictures 
in  the  rectum  or  in  the  sigmoid  flexure  of  the  colon  may  be  readily 


DISEASES  OF  THE  ABDOMEN.  465 

discerned,  but  a  stricture  at  the  lower  part  of  the  descending  colon 
may  exist,  though  the  hand  be  unable  to  discover  it. 

We  might  with  palpation  consider  the  results  obtained  by  the  use 
of  bougies  and  of  tubes,  such  as  the  stomach-tube.  But  these  will 
be  more  appropriately  considered  when  discussing  the  diseases  of 
individual  organs, 

PERCUSSION. 

Percussion  is,  in  the  study  of  abdominal  affections,  only  less  valu- 
able than  palpation.  By  it  we  can  circumscribe  the  different  organs 
with  accuracy ;  we  can  judge  of  the  position  of  the  stomach  and 
intestines ;  we  can  limit  the  distended  bladder,  and  fix  the  borders  of 
the  liver  and  spleen.  By  its  aid,  further,  we  can  tell  whether  a  dis- 
tention of  the  abdomen  is  produced  by  air,  or  by  a  solid  tumor,  or  by 
liquid.  But,  without  entering  here  into  particulars  as  to  its  use  in 
individual  disorders,  we  shall  examine  the  results  when  applied  to 
the  healthy  abdomen. 

To  render  percussion  a  trustworthy  interpreter  of  the  state  of  the 
abdominal  viscera,  the  patient  should  be  placed  in  the  same  position 
as  for  palpation.  The  sounds  are  best  elicited  by  mediate  percussion, 
and  where  great  accuracy  is  desirable,  we  may  advantageously  make 
use  of  auscultatory  percussion  or  the  plionendoscope.  But  for  correct 
deductioji  we  must  be  acquainted  with  the  relations  of  the  parts  which 
the  abdominal  walls  conceal  from  view,  and  take  into  account  that 
during  the  digestive  process  the  contents  and  position  of  these  organs 
may  vary  sufficiently  to  modify  the  percussion  sound. 

To  begin  with  the  airless  viscera.  The  liver  is  one  of  the  easiest 
organs  to  limit.  We  determine  its  upper  boundary  by  striking  with 
moderate  force  in  a  line  from  somewhat  above  the  right  nipple  towards 
the  lower  part  of  the  thorax,  until  marked  resistance  and  dulness  tell 
us  that  a  solid  organ  has  been  reached.  At  this  point  we  make  a 
mark ;  then  we  percuss  downward  from  near  the  median  line,  and 
above  the  dulness  just  obtained ;  then  from  the  axilla  downward ; 
then  posteriorly  from  beneath  the  lower  angle  of  the  scapula  ;  and  so 
on,  until  the  line  traced  reaches  the  vertebral  column. 

.  The  dulness  thus  elicited  marks  the  upper  boundary  of  the  liver ; 
at  least  of  the  portion  more  directly  in  contact  with  the  abdominal 
walls.  Anteriorly  it  extends  from  the  lower  extremity  of  the  sternum 
to  between  the  fifth  and  sixth  rilDS  ;  at  the  side,  the  dulness  is  gener- 
ally in  the  seventh  intercostal  space ;  near  the  vertebral  column,  it  is 
on  a  level  with  the  tenth  or  the  eleventh,  more  rarely  with  the  ninth, 
interspace.  The  dulness  of  the  left  lobe  reaches  nearly  two  inches 
across  the  median  line  ;  but  the  heart  lies  here  so  near  to  the  liver  that 


466  MEDICAL  DIAGNOSIS. 

we  cannot  with  accuracy  distinguish  the  flat  sound  of  the  one  from 
the  flat  sound  of  the  other. 

After  the  upper  border  has  been  fairly  traced  out  anteriorly,  later- 
ally, and,  if  thought  necessary,  posteriorly,  we  determine  the  inferior 
margin  of  the  organ.  This  is  readily  effected  by  percussing  down- 
ward from  the  already  ascertained  line  of  dulness,  and  noting  where 
Jhe  large  intestine  sends  forth  its  distinct  tympanitic  sound.  To 
determine  the  lower  border  correctly,  the  pleximeter  must  be  pressed 
firmly  on  the  integuments,  and  the  stroke  of  the  finger  be  slight ;  for  if 
it  be  strong,  we  obtain  the  sound  of  the  surrounding  hollow  viscera 
through  the  thin  layer  of  liver  which  covers  them,  and  before  we  have 
arrived  at  its  margin.  This  mode  of  procedure  is  different  from  the 
one  pursued  to  determine  the  height  to  which  the  liver  rises,  because 
the  position  of  the  parts  is  different.  Superiorly,  the  lung  descends 
between  the  surface  and  that  portion  of  the  convex  surface  of  the  liver 
which  fits  into  the  diaphragm,  and  it  requires  strong  percussion  to 
bring  out  the  dulness  of  the  deep-seated  solid  organ.  By  forcible  per-  , 
cussion  we  detect  a  decided  loss  of  the  pulmonary  resonance  at  about 
the  fourth  intercostal  space. 

The  inferior  border  of  the  liver,  anteriorly,  is  generally  found  to  lie 
immediately  at,  or  to  project  below,  the  last  rib ;  posteriorly,  we  can- 
not determine  this  border  positively,  for  it  becomes  continuous  with 
the  dulness  occasioned  by  the  right  kidney.  The  lower  margin  of  the 
left  lobe  is  commonly  met  with  at  the  upper  third  of  a  line  drawn  from 
the  ensiform  cartilage  to  the  umbilicus.  A  distended  gall-bladder  may 
cause  a  strictly  outlined  dulness  below  the  surrounding  liver.  The 
percussion  dulness  of  the  liver  is  everywhere  lowered  by  a  full  inspi- 
ration. 

The  spleen  is  not  so  easily  circumscribed  as  the  liver.  Indeed,  if 
the  stomach  or  the  intestines  be  distended,  it  is  difficult  to  detect  the 
dull  sound  of  the  spleen.  To  find  its  limits,  we  must  place  the  patient 
on  his  right  side,  with  his  legs  flexed ;  or  let  him  stand  erect,  and  then 
begin  to  strike  with  some  force  in  a  line  from  the  axilla  to  the  crest  of 
the  ilium.  At  the  ninth,  or  sometimes  at  the  tenth,  rib,  the  sound 
becomes  dull,  and  there  is  much  greater  resistance  to  the  finger.  Here 
is  the  upper  boundary  of  the  spleen.  We  mark  the  spot,  and  continue 
to  percuss  in  the  same  line  until,  at  about  the  twelfth  rilD,  we  arrive  at 
the  lower  boundary  of  the  organ,  as  indicated  by  the  distinct  tympa- 
nitic sound  of  the  intestines. 

After  the  vertical  diameter  has  been  thus  ascertained,  the  horizon- 
tal is  readily  determined  by  percussing  from  the  median  line  to  a  point 
between  the  lines  which  trace  the  superior  and  inferior  margins,  and 


DISEASES  OF  THE  ABDOMEN.  467 

by  noticing  where  the  sound  of  the  stomach  gives  way  to  the  duh 
sound  of  the  sohd  viscus.  When  these  three  points  have  been  de- 
cided upon,  we  have  learned  enough  for  practical  purposes.  We  may 
then,  if  we  choose,  percuss  posteriorly ;  but  we  cannot  circumscribe 
the  spleen  with  any  accuracy  behind,  because  its  dulness  becomes 
continuous  with  that  of  the  left  kidney. 

The  average  size  of  the  spleen  is  four  inches  in  length  and  three  in 
width  ;  but  it  may  in  a  diseased  state  increase  to  twice  or  three  times 
that  size.  When  the  viscus  eludes  detection  by  percussion,  we  may 
infer  it  to  be  small ;  provided  the  stomach  and  intestines  be  not  much 
distended  with  gas. 

The  kidneys  cannot  be  limited  with  anything  like  accuracy,  except 
at  their  inferior  and  outer  borders,  where  the  dull  sound  they  occasion 
is  surrounded  by  the  intestinal  resonance.  This  dulness  extends  some- 
what lower  during  a  full  inspiration. 

In  setting  limits  to  the  stomach  and  intestines^  by  means  of  percus- 
sion, we  have  to  judge  more  between  sounds  of  different  degree,  but 
similar  to  one  another,  than  between  sounds  of  different  character. 
Nor  are  the  tones  elicited  always  the  same  over  the  same  spot ;  they 
vary  as  the  contents  of  the  hollow  viscera  vary.  We  can  make  use  of 
this  circumstance  for  purposes  of  diagnosis.  In  percussion  of  the 
stomach  and  of  the  intestines  we  may  often  with  great  advantage 
resort  to  auscultatory  percussion. 

The  stomach,  when  not  unusually  distended  with  gas  or  with  food, 
renders  a  sound  which  is  hollow,  ringing,  and  tympanitic  to  a  certain 
degree,  yet  which  is  not  tympanitic  as  that  of  the  intestine  is.  To 
determine  the  boundaries  of  the  stomach,  it  is  necessary  to  mark  out 
first  the .  lower  margin  of  the  liver,  for  it  covers  a  portion  of  the 
stomach ;  then  the  heart  and  the  inner  border  of  the  spleen.  The 
part  which  lies  between  these  solid  viscera  yields  the  sound  of  the 
stomach,  mixed  at  one  point,  namely,  to  the  left  of  the  apex  of  the 
heart,  with  the  resonance  of  the  lung.  Near  this  spot,  about  opposite 
to  the  seventh  rib,  and  on  the  left  of  the  body  of  the  tenth  dorsal 
vertebra,  the  cardiac  extremity  of  the  stomach  is  situated ;  below  it  is 
the  bulk  of  the  organ  ;  the  pylorus  is  on  the  body  of  the  first  lumbar 
vertebra,  four  to  six  centimetres  to  the  right  of  the  median  line,  on  a 
level  with  the  tip  of  the  xiphoid  cartilage,  between  the  right  edge  of 
the  sternum  and  a  vertical  line  passing  through  the  nipple.  Fully 
three-fourths  of  the  stomach  is  to  the  left  of  the  median  line.  The 
cardiac  end  is  immovable ;  the  pylorus,  seated  from  six  to  eight  centi- 
metres lower  than  the  cardiac,  has  a  moderate  mobility  ;  in  infants  it 
is  nearer  the  median  line  than  in  adults. 


468 


MEDICAL  DIAGNOSIS. 


To  ascertain  the  lower  border  of  the  stomach,  we  percuss  gently 
in  a  downward  direction,  until  the  alteration  in  sound  shows  that  we 
are  striking  over  the  colon.  The  difference  is  at  times  very  obvious, 
at  times  very  slight.  It  is  readily  detected  if  the  stomach  contain 
either  solid  or  liquid  ingesta.  Availing  ourselves  of  this  fact,  we  may 
with  advantage  let  the  patient  swallow  a  glass  of  water.  By  placing 
him  in  the  erect  position,  the  fluid  gravitates  to  the  greater  curvature, 


Fig.  53. 


Eesults  of  abdominal  percussion,  as  set  forth  in  the  text.  The  dark  shades  indicate  marked 
dulaess ;  the  light  shading  exhibits  a  lessening  of  the  clear  or  of  the  tympanitic  character  of  the 
sound, — an  approach  to  dullness. 


and  the  hue  of  comparative  dulness  indicates  the  lower  margin  of  the 
stomach,  which  is  generally  found  one  to  two  inches  above  the  umbili- 
cus. In  men  the  lower  border  of  the  stomach  is  a  little  higher  than 
in  women  ;  in  working-women  it  is  higher  than  in  other  women ;  in 
children  under  fifteen  years  of  age  it  very  rarely  extends  to  the  um- 
bilicus ;  in  persons  of  fifty  it  is  not  unusual  for  it  to  do  so.  In  strong, 
healthy  people  the  whole  position  of  the  stomach  is  more  horizontal 


DISEASES  OF  THE  ABDOMEN.  469 

than  in  weak  ones.^  Deep  percussion  is  used  to  limit  tlie  superior 
line,  and  light  percussion  the  inferior  line,  of  the  stomach. 

Another  method  to  determine  the  limits  of  the  organ,  as  well  as 
whether  the  pylorus  is  still  capable  of  self-closure  in  the  direction 
of  the  duodenum,  or  is  permanently  patent,  has  been  proposed  by 
Epstein.  It  consists  in  the  distention  of  the  stomach  by  means  of 
carbonic  acid,  generated  by  first  letting  the  patient  swallow  about 
a  teaspoonful  of  sodium  bicarbonate  dissolved  in  a  glass  of  water 
and  then  an  equal  amount  of  a  like  solution  of  tartaric  acid.  The 
same  end  may  be  attained  by  direct  insufflation  by  means  of  inject- 
ing air  into  the  stomach  through  a  tube.  The  stomach  becomes  very 
■  much  distended,  and  emits  a  deep  tympanitic  note  on  percussion, 
unlike  that  over  the  intestines  ;  but  if  the  pylorus  be  incapable  of 
closure,  the  intestines  too  become  swollen,  and  their  tympanitic  note 
is  changed. 

The  colon  yields,  in  all  its  parts,  a  sound  of  a  purer  tympanitic  char- 
acter than  the  stomach,  the  note  of  Avhich  is,  indeed,  in  many  respects 
more  amphoric  than  tympanitic.  When  the  tube  contains  faeces,  the 
sound  is  modified ;  and  as  these  are  prone  to  accumulate  on  the  left 
side  in  the  descending  colon,  and  especially  where  this  passes  into  the 
iliac  fossa,  it  is  usually  not  so  resonant  as  the  ascending,  colon.  The 
small  intestines^  unless  they  are  filled  with  fluid  or  solids,  or  distended 
with  gas,  render  a  sound  of  higher  pitch  and  of  smaller  volume  than 
the  surrounding  large  intestine,  and  by  the  less  deep-toned  sound  their 
position  may  be  accurately  determined.  Artificial  distention  of  the 
colon,  by  generating  carbonic  acid  in  it  by  means  the  same  as  just 
mentioned  passed  into  the  lower  bowel,  has  been  advocated  for  diag- 
nostic purposes  by  Ziemssen.^  It  enables  us  to  distinguish  with  ease 
the  outline  of  the  large  intestine,  and  shows  whether  there  is  commu- 
nication with  adjacent  organs,  such  as  the  stomach,  the  bladder,  or 
the  small  intestine.  Anomahes  of  position  and  form  of  the  bowel  give 
rise  to  differences  in  the  results  of  abdominal  percussion,  as  has  been 
well  shown  in  a  careful  clinical  study  by  Curschmann.^ 

The  position  of  the  viscera  in  the  pelvis  cannot  be  ascertained  by 
means  of  percussion.  It  is  only  when  the  bladder  is  much  distended, 
or  the  uterus  augmented  in  size,  that  the  outline  of  either  can  be  traced 
on  the  walls  of  the  abdomen. 


1  Obrastzow,  Deutsches  Arch.  f.  klin.  Med.,  Bd.  xliii.,  1888. 

^  Deutsches  Archiv  fiir  khnische  Medicin,  Bd.  xxxiii.,  June,  1883. 

Mbid.,  Bd.  liii.,  June,  1894. 


470  MEDICAL   DIAGNOSIS. 

AUSCULTATION. 
Auscultation  is  serviceable  in  aiding  in  the  detection  of  an  abdom- 
inal aneurism ;  and  sometimes  an  enlarged  spleen  gives  rise  to  a  dis- 
tinct blowing  murmur ;  or  the  rubbing  of  a  roughened  peritoneum' 
may  occasion  a  friction  sound ;  but,  on  the  whole,  the  application  of 
the  stethoscope  to  the  abdominal  walls  is  rarely  of  aid  except  in  de- 
termining the  significance  of  abdominal  pulsation.  In  health  no  con- 
stant sound  is  heard  save  that  of  the  aorta ;  for  the  rush  of  blood 
through  the  other  arteries,  or  through  the  veins,  produces  no  apprecia- 
ble murmur.  When  the  stomach  is  distended  with  air  and  contains 
liquid,  sounds  possessing  a  metallic  character  are  perceived,  which  an 
inexperienced  observer  is  apt  to  consider  as  originating  in  the  lungs,  . 
over  which,  in  truth,  they  are  often  audible.  Similar  sounds,  together 
with  succussion-phenomena  may  be  elicited  when  gas  and  liquid  are 
present  together  in  the  peritoneal  cavity, — as  a  result  of  perforative 
peritonitis.  The  passage  of  gas  through  the  intestines  gives  rise  to 
those  peculiar  noises  termed  "  borborygmi."  In  cases  of  stenosis  of 
the  bowel  a  hissing  sound  is  sometimes  audible  during  peristaltic 
activity.  In  the  pregnant  state,  auscultation  is  of  value  in  detecting 
the  pulsations  of  the  foetal  heart  and  the  utero-placental  murmur. 

SECTION  I. 

DISEASES    OF    THE    STOMACH. 

It  is  only  within  the  last  few  years  that  any  attempts  have  been 
made  to  bring  to  bear  on  the  diseases  of  the  stomach  modern  means 
of  research.  Most  of  these  attempts  have  had  as  their  aim  to  ascertain 
the  exact  anatomical  changes  and  the  modifications  in  the  secretions 
which  give  rise  to  the  symptoms  commonly  referred  to  perverted  func- 
tion ;  and  they  have  been  successful  to  a  decided  degree. 

The  stomach  is  examined  partly  by  physical  exploration  by  the 
methods  just  detailed,  and  partly  by  paying  attention  to  the  chemical 
changes  which  attend  the  digestive  acts. 

With  reference  to  the  physical  examination,  there  are  some  special 
means  that  may  be  employed  with  advantage.  To  determine  the  rel- 
ative sensitiveness  over  the  epigastrium.  Boas  ^  measures  the  pressure 
by  an  algesimeter.  The  normal  tolerance  is  from  eighteen  to  twenty 
pounds.  In  cases  of  gastric  ulcer,  pain  is  complained  of  at  a  pressure 
of  from  two  to  four  pounds.  The  direct  application  of  eledncify  to 
the  coats  of  the  stomach  as  a  test  of  their  motility  has  been  also  made 


Miinchener  Medicinische  Woclienschrift,  Sept.  1893. 


DISEASES  OF  THE  STOMACH.  471 

use  of;  but,  valuable  as  this  agent  has  proved  therapeutically,  it  has 
not  shown  itself  valuable  diagnostically. 

Ingenious  instruments  have  been  devised  for  illuminating  and  in- 
specting the  interior  of  the  stomach.  By  means  of  the  gastrodiaphane 
of  Einhorn,^  which  consists  of  a  soft  rubber  tube  through  which  pass 
wires  connected  with  a  source  of  electricity  and  provided  with  an  in- 
candescent lamp  enclosed  securely  in  glass,  the  size  and  outlines  of  the 
stomach,  as  well  as  the  density  of  its  wall,  can  be  made  out.  The 
patient  is,  on  an  empty  stomach,  first  made  to  swallow,  or  there  are 
introduced  through  a  tube,  one  or  two  pints  of  water ;  the  tube  is  passed 
into  the  stomach  in  the  customary  manner,  and  the  appearance  of  the 
light  is  observed  in  a  dark  room.  A  reddish  luminous  zone  upon  the 
abdomen  indicates  the  outline  and  the  position  of  the  stomach ;  and 
dark  spots  may  enable  us  to  judge  accurately  of  the  size,  shape,  and 
position  of  tumors.  Gastrodiaphany  has  also  been  made  use  of  in 
the  diagnosis  of  oesophageal  diverticula,  in  which,  moreover,  the  swal- 
lowing sounds  are  frequently  audible.^ 

The  gastrosGope  of  Mikulicz  is  a  more  complicated  instrument,  by 
means  of  which  it  is  possible  to  inspect  directly  limited  portions  of  the 
interior  of  the  stomach.  A  revolving  sound,  the  gyromek,  has  been 
invented  by  F.  B.  Turck.^  The  revolutions  can  be  felt  upon  the  ab- 
dominal wall,  and  the  various  parts  of  the  stomach,  especially  the 
greater  curvature,  accurately  located.  If  the  movements  of  the  sound 
are  distinctly  felt  on  the  parietes,  tumors  of  the  anterior  wall  and  of 
the  fundus  can  be  excluded. 

It  is  always  important  to  study  the  activity  of  the  movements  of 
the  stomach,  and  this  is  generally  done  partly  by  noting  how  long  it 
will  take  a  trial  meal  to  digest  completely,  partly  by  chemical  means 
to  be  presently  detailed.  But  the  object  .has  been  also  sought  to  be 
attained  by  instrumental  aid.  With  this  view,  Turck  ^  has  introduced 
a  gastric  motormeter^  which  consists  of  a  collapsed  rubber  bag  with  a 
fme  rubber  tube  attached  that  is  connected  with  a  manometer  ;  thus 
both  degree  and  force  of  movement  are  registered.  The  bag  is  inflated 
with  air  after  being  passed  into  the  stomach.  Another  way  of  deter- 
mining the  mechanical  action  of  the  stomach,  as  well  as  of  recording 
its  movements,  is  by  the  gastrograph,  the  invention  of  Einhorn.'' 

The  accurate  chemical  study  of  the  secretions  and  of  the  contents 

'  New' York  Medical  Journal,  Dec.  1892. 

'^  Jung,  Amer.  Journ.  Med.  Sci.,  April,  1900. 

^  Journal  of  the  American  Medical  Association,  March,  1895. 

*  Proceedings  of  the  American  Medical  Association,  May,  1895. 

*  New  York  Medical  Journal.  Sept.  1894.    * 


472  MEDICAL  DIAGNOSIS. 

of  the  stomach  is  leading  to  great  aclvances  iii  the  investigation  of  its 
affections,  as  has  been  proved  especially  by  the  labors  of  Leube,  of 
Ewald,  of  Boas,  and  of  others.  We  get  the  contents  of  the  stomach 
for  examination  from  two  to  four  hours  after  a  full  or  •'  trial  meal."' 
given  as  a  mid-day  dinner,  and  consisting  of  four  hundred  grammes  of 
soup,  sixty  grammes  of  scraped  meat,  and  fifty  grammes  of  white 
bread :  of  this,  if  the  act  of  digestion  have  been  normally  carried  on 
and  the  chyme  have  passed  on  into  the  small  intestme,  notliing  remains 
after  the  lapse  of  six  or  seven  hours  but  a  clear  licjuid.  Ewald  has 
substituted  a  light  breakfast  trial  meal,  a  small  amount  of  dry  bread 
or  of  toast,  from  thirty-five  to  seventy  grammes,  and  a  third  of  a  litre, 
about  eleven  fluidounces,  of  warm  water  or  weak  tea,  which,  given 
on  an  emi^ty  stomach,  allows  the  gastric  contents  to  be  tested  in  an 
hour,  a  matter  often  of  great  convenience.  The  material  for  examina- 
tion is  obtained  by  means  of  an  elastic  tube,  preferably  of  soft  rubber, 
about  seventy-five  centimetres  long  by  six  centmietres  in  diameter, 
and  provided  with  an  opening  at  its  conical  extremity  and  others  at 
the  side.  The  licjuid  is  removed  from  the  stomach  by  pressure  oyer 
the  epigastrium,  or  by  aspiration  by  means  of  a  hand  ball  apparatus. 
The  results  of  these  trial  meals  should  be  filtered  for  accurate  exami- 
nation. When  vomiting  takes  place  an  examination  of  the  ejecta  may 
yield  evidence  of  the  digestive  and  motor  activity  of  the  stomach,  or 
of  the  presence  of  abnormal  elements. 

The  next  points  to  determine  are  the  composition  of  the  gastric 
juice  and  its  digestive  power.  We  first  have  to  ascertain  if  the  liquid 
obtained  be  acid,  how  great  its  total  acidity,  and  what  its  acid  nature 
is  o^\ing  to.  The  acid  of  the  gastric  juice  is  hydrochloric.  Lactic 
acid  plays  no  part  in  the  normal  digestive  process.  When  the  latter 
is  present,  it  is  derived  from  the  food,  or  it  may  result  from  the  fer- 
mentative activity  of  bacteria.  Its  presence  is  indicative  of  stagna- 
tion of  the  gastric  contents  or  of  hydrochloric  acid  deficiency.  The 
total,  acidity  one  hour  after  an  Ewald  test  breakfast  is  normally  about 
60.  The  average  amount  of  free  hydrochloric  acid  is  fi'om  20  to  30, 
or  equal  to  0.1  to  0.2  per  cent.  The  best  indicator  for  the  total  acidity 
is  phenolphthalein. 

To  determine  the  presence  of  free  acid  in  the  gastric  contents,  the 
most  delicate  reagent  is  Congo  red,  wliich  may  be  employed  in  solu- 
tion or  in  the  form  of  paper  impregnated  there^^dth.  Free  acid  causes 
an  azure-blue  color;  acid  salts  have  no  effect.  A  solution  of, methyl- 
violet  may  also  be  employed,  which  is  turned  into  a  deep  blue  ;  or 
trop^olin,  which  in  a  saturated  watery  solution  is  a  dark  yellowish-red 
liquid  that  on  contact  with  any  free  acid  becomes  dark  brown,  while 


DISEASES  OF  THE  STOMACH.  473 

with  acid  salts  it  assumes  a  straw-colored  tint.  To  ascertain  the  pres- 
ence of  hydrochloric  acid  a  good  test  is  Gtinzberg's  phloroglucin- 
vanillin  solution.  It  consists  of  two  grammes  of  phlorogiucin  and  one 
gramme  of  vanillin,  with  thirty  grammes  of  absolute  alcohol.  A  few 
drops  of  this  solution,  which  is  of  a  yellowish  color,  added  to  a  similar 
quantity  of  a  liquid  containing  hydrochloric  acid,  when  gently  heated, 
turn  it  at  once  a  bright-red  hue  ;  while  the  reagent  remains  unchanged 
by  organic  acids,  such  as  lactic  or  acetic  acid.  Boas  ^  recommends  a 
solution  containing  resublimated  resorcin  five  grammes,  white  sugar 
three  grammes,  dilute  alcohol  sufficient  to  make  one  hundred  grammes. 
Of  this,  three  or  four  drops  are  added  to  five  or  six  drops  of  the  gastric 
contents,  and  the  whole  is  gently  heated  to  dryness  ;  a  bright-red  hue 
results  from  the  jDresence  of  free  hydrochloric  acid.  The  simplest  and 
quickest  test  is  the  dimethyl-amido-azo-benzol  test  of  Topfer,  and  it 
is  one  coming  mto  general  use.  Both  Hemmeter^  and  Stockton^ 
regard  it  as  the  best.  A  few  drops  of  a  0.5  per  cent,  alcoholic  solution 
added  to  the  stomach  contents  develop  a  cherry-red  color  if  there  be 
free  hydrochloric  acid.     The  acidity  referable  to  this  is  .35  degrees.* 

To  determine  the  presence  of  lactic  acid,  a  matter  often  of  very  gTeat 
value  for  diagnostic  purposes,  a  solution  is  prepared  of  ten  cubic  cen- 
timetres of  a  four  per  cent,  solution  of  carbolic  acid,  twenty  cubic 
centimetres  of  water,  and  one  or  two  drops  of  a  solution  of  ferric 
chloride.  This  has  an  amethyst-blue  color,  which  in  the  presence  of 
-lactic  acid  becomes  lemon-yellow  or  canary-yellow. 

Yet  the  test  is  not  altogether  trustworthy,  as  sugar,  peptone,  alco- 
hol, and  other  substances  also  cause  a  yellowish  coloration ;  further,  it 
is  interfered  with  by  the  presence  of  phosphates  and  hydrochloric  acid 
in  considerable  amount.  To  remove  these  sources  of  possible  fallacy, 
Strauss  '"  has  recommended  the  following  procedure.  Into  a  graduated 
funnel  are  introduced  five  cubic  centimetres  of  gastric  juice  and  twenty 
cubic  centimetres  of  ether,  and  the  mixture  is  vigorously  shaken. 
When  the  fluids  have  separated,  the  lower  five  cubic  centimetres  are 
permitted  to  escape,  and  sufficient  distilled  water  is  added  to  make 
twenty-five  cubic  centimetres,  followed  by  two  drops  of  a  solution 
made  up  of  one  part  of  ferric  chloride  and  nine  parts  of  distilled  water. 
The  mixture  is  again  shaken  and  the  lower  watery  layer  appears. of 

^  Diagnostik  u.  Therapie  dex'  Magenkrankheiten,  3.  Aufl.,  1.  Theil,  1894,  p.  149. 
2  Diseases  of  the  Stomach,  2d  edit.,  1900. 
^  System  of  Practical  Medicine  l)y  American  Authors,  vol.  iii. 
*  Hemmeter,  ibid.,  p.  1(35. 

5  Berliner  klinische  Wochenschrift,  1895,   No.    37,    cited  by  Sahli,    Lehrb.  d. 
klin.  Untersnch.,  1899. 


474  MEDICAL  DIAGNOSIS. 

a  deep  yellowish  green  when  more  than  one  per  cent,  of  lactic  acid  is 
present. 

The  presence  of  volatile  fatty  acids,  butyric  acid,  acetic  acid,  etc.^ 
in  noteworthy  amounts,  may  be  recognized  by  the  characteristic  odor. 

The  degree  of  acidity  of  the  gastric  juice  is  more  difficult  to  deter- 
mine than  the  presence  of  the  acids.  Ewald  recommends,  as  a  ready 
way,  to  titrate  with  a  one-tenth  normal  sodium  hydroxide  solution^ 
ascertaining  the  saturation  point  with  litmus  paper  or  with  phenol- 
phthalein.  Topfer's  test  is  now  much  employed  for  the  quantitative 
analysis  of  the  stomach  acids,  and  enables  us  to  estimate  not  only 
the  amount  of  free  hydrochloric  acid,  but  also  the  acidity  due  to  the 
organic  acids  and  the  acid  salts,  as  well  as  to  the  hydrochloric  acid 
that  exists  in  combination  with  the  albuminous  bodies.  In  Topfer's 
method  three  indicators  are  used.  A  few  drops  of  a  0.5  per  cent, 
alcoholic  solution  of  dimethyl-amido-azo-benzol  added  to  ten  cubic 
centimetres  of  filtered  gastric  juice  are  titrated  with  a  decinormal 
solution  of  caustic  soda  until  the  red  color  due  to  the  free  hydro- 
chloric acid  changes  to  a  clear  yellow.  A  few  drops  of  a  one  per 
cent,  aqueous  solution  of  alizarin  added  to  a  second  portion  of  ten 
cubic  centimetres  of  the  gastric  juice  become,  when  titrated  suffi- 
ciently with  the  solution  of  caustic  soda,  clear  violet,  and  the  test 
indicates  the  amount  of  free  hydrochloric  acid,  of  organic  acids,  and 
organic  salts.  A  third  portion  treated  with  -a  one  per  cent,  alcoholic 
solution  of  phenolphthalein  turns  dark  red  when  all  the  acids,  in- 
cluding the  combined  hydrochloric  acid,  have  been  saturated.  From 
these  different  data  the  amount  of  the  entire  acidity,  as  well  as  of  the 
separate  acids  can  be  calculated.^ 

We  may  test  the  solvent  power  of  the  gastric  juice  by  taking  a 
piece  of  hard-boiled  e%^  and  adding  the  gastric  juice  in  a  test-tube. 
Heated  in  a  culture  oven,  the  eg^  albumin,  if  the  gastric  juice  be  nor- 
mal in  pepsin,  will  be  dissolved  in  about  three  hours.  Propeptone  and 
peptone  are  determined  by  the  biuret  reaction.  The  presence  of  the 
lab-ferment  or  rennet-ferment  is  shown  by  the  coagulation,  in  from  ten 
to  fifteen  minutes,  of  between  five  and  ten  cubic  centimetres  of  fresh, 
unboiled  milk  of  neutral  reaction  exposed  in  an  incubator  to  the 
action  of  from  three  to  five  drops  of  gastric  juice.  In  the  absence  of 
lab-ferment  the  presence  of  lab-zymogen  is  shown  by  the  formation 
of  a  dense  coagulum  within  ten  or  fifteen  minutes,  when  a  mixture 
of  equal  parts  of  unboiled  milk  and  gastric  juice  rendered  alkaline  by 
lime-water  is  placed  in  an  incubator.     After  an  hour  from  the  time 

^  For  examples  refer  to  Hemmeter,  loc.  eit. 


DISEASES  OF  THE  STOMACH.  475 

Ewald's  trial  breakfast  has  been  taken  there  should  be  no  reaction  for 
starch  found  by  Lugol's  solution  in  the  filtered  liquid  of  digestion.  An 
excess  of  hydrochloric  acid  in  the  gastric  juice  quickly  checks  the 
digestion  of  starch  begun  in  the  mouth  by  the  saliva,  while  a  deficiency 
permits  its  completion.  Under  the  first  condition,  therefore,  the  reac- 
tion for  starch  will  be  prolonged  ;  under  the  latter  shortened. 

The  absorptive  activity  of  the  gastric  mucous  membrane  is  shown 
by  the  rapidity  with  which  iodide  appears  in  the  saliva  after  the  inges- 
tion of  one  and  one-half  grains  of  potassium  iodide  carefully  enclosed 
in  a  gelatin  capsule.  In  health  the  characteristic  blue  coloration  is,  as 
a  rule,  obtained  with  starch-paper  in  the  course  of  ten  or  fifteen  min- 
utes. This  test  may  be  modified  so  as  to  indicate  the  digestive  activity 
of  the  gastric  juice  by  wrapping  the  potassium  iodide  in  some  im- 
permeable material  fastened  with  strands  of  fibrin.  Disintegration  of 
the  fibrin  permits  of  the  escape  and  absorption  of  the  iodide,  and  the 
time  of  appearance  of  iodine  in  the  saliva  is  an  index  both  of  digestive 
and  absorptive  activity. 

The  motor  activity  of  the  stomach  is  determined  by  the  develop- 
ment of  a  violet  color  on  the  addition  of  a  drop  or  two  of  a  neutral 
solution  of  ferric  chloride  to  two  or  three  drops  of  the  urine  placed 
upon  bibulous  paper,  after  the  ingestion  .of  fifteen  grains  of  salol  in 
gelatin  capsules  at  the  height  of  digestion.  The  violet  color  shows  the 
presence  of  salicyluric  acid,  which  is  in  the  majority  of  persons  ob- 
served in  the  course  of  from  sixty  to  seventy-five  minutes,  and  does  not 
persist  for  more  than  twenty-six  or  twenty-seven  hours.  But  there 
are  still  many  clinicians  who  prefer  the  older  method  of  examining 
the  contents  of  the  stomach,  after  trial  meals,  with  a  view  to  determine 
the  gastric  motility.  Leube's  method  consists  in  removing  the  con- 
tents of  the  organ  six  or  seven  hours  after  a  trial  dinner,  or  they  may 
be  examined  an  hour  after  Ewald's  trial  breakfast.  In  either  case,  the 
stomach  should  then  contain  nothing  but  the  liquid  of  digestion ;  two. 
hours  after  the  trial  breakfast  it  should  be  empty.  If  more  than  forty 
cubic  centimetres  are  obtained  an  hour  after  Ewald's  trial  breakfast, 
it  shows  insufficient  motor  activity. 

The  symptoms  which  are '  constantly  met  with  in  derangements  of 
the  stomach,  whether  organic  or  functional,  are  loss  of  appetite, 
nausea  and  vomiting,  acidity,  flatulency,  and  pain. 

Loss  of  Appetite. — This  manifests  itself  in  various  ways.  It 
may  amount  to  absolute  repugnance  to  taking  any  kind  of  food,  or 
may  be  merely  an  inability  to  partake  of  certain  articles.  What  the 
loss  of  appetite  depends  on,  we  do  not  know.  That  nervous  influence 
has  something  to  do  with  the  anorexia,  is  shown  by  the  sudden  dep- 


476  MEDICAIi  DIAGNOSIS. 

rivation  of  all  desire  to  eat  when  any  strong  impression  is  made  on 
the  nervous  system, — such  as  that-  caused  by  the  unexpected  receipt 
of  unwelcome  news.  The  collection  of  epithelium  on  the  mucous 
membrane  is  also  connected  with  a  marked  diminution  of  the  appe- 
tite ;  for  with  a  tongue  much  coated,  absolute  disgust  at  the  mere 
thought  of  taking  food  often  exists,  which  yields  to  relish  for  food  as 
soon  as  the  tongue  begins  to  clear. 

Attending  lost  appetite,  we  meet  sometimes  with  great  emaciation 
and  with  signs  as  if  even  the  small  quantity  of  food  taken  were  not 
absorbed  into,  or  utterly  failed  to  nourish,  the  system.  There  is  apt  to 
be  sensitiveness  over  the  abdomen,  and  spots  of  particular  sensitive- 
ness exist  which  correspond  to  the  situation  of  the  mesenteric  glands. 
We  find,  however,  no  evidence  of  organic  disease,  either  in  the  abdo- 
men or  in  the  lungs  ;  nor  does  this  pseudo  tabes  mesenterica,  if  I  may 
so  call  it,  occur,  like  the  disease  it  simulates,  in  scrofulous  or  tubercu- 
lar patients.  I  have  met  with  a  number  of  cases,  chiefly  in  young 
women  with  lowered  vital  force,  fond  of  excitement,  and  living  indo- 
lent lives.  Some  were  hysterical,  others  not.  But  in  all  the  complaint 
seemed  to  be  due  to  deficient  nerve-power,  with  impaired  function  of 
the  stomach,  and  possibly  of  the  abdominal  glands.  This  disorder 
is  probably  the  same  as  that  described  by  Gull  as  hysteric  apepsia,^ 
and  kindred  to  the  one  delineated  by  Lasegue  as  hysteric  anorexia.^ 

Instead  of  the  appetite  being  lost,  it  may  be  capricious,  or  even 
ravenous.  There  is  great  craving  for  food  in  diabetes.  A  craving  for 
food  is  not  often  combined  with  a  structural  lesion  of  the  stomach: 
Yet  we  occasionally  meet  with  it  in  persons  affected  with  gastric  ulcer. 
It  is  common  to  find  it  in  those  who  suffer  froin  neuralgia  of  the 
stomach.  And  sometimes  in  cases  of  mere  nervous  gastric  disturb- 
ance, with  or  without  pain,  there  is  an  extraordinary  exaggeration  of 
the  appetite,  a  bulimia :  the  patient  eats  largely  eight  or  even  fifteen 
times  a  day,  digests  his  food,  yet  is  constantly  hungry. 

The  feeling  of  thirst  does  not  lessen  when  the  desire  for  food  does. 
On  the  contrary,  it  usually  increases  when  the  latter  diminishes. 

Excessive  Acidity  of  the  Stomach. — Excessive  acidity  occurs 
from  various  causes.  The  gastric  juice  may  be  secreted  in  great  quan- 
tities, or  it  may  contain  an  abnormal  amount  of  acid.  But  excessive 
acidity  is  far  more  frequently  due  to  the  decomposition  of  food  and  to 
a  process  of  fermentation  dependent  rather  upon  an  insufficient  amount 
or  altered  state  of  the  gastric  solvent.     It  then  manifests  itself  only 

1  Transactions  of  the  Clinical  Society,  vol.  vii.,  1874. 

2  Archives  Generales  de  Medecine,  April,  1873.  • 


DISEASES  OF  THE  STOMACH.  477 

after  meals.  When  the  mucous  membrane  is  covered  with  a  tenacious 
mucus  or  with  thick  layers  of  epithelium,  slow  digestion  and  acidity. 
from  fermentation  result ;  because,  although  the  gastric  juice  is  suffi- 
cient, it  cannot  mix  as  readily  with  the  aliment. 

The  acids  formed  in  the  stomach  are,  besides  the  hydrochloric  acid 
of  the  gastric  juice,  lactic  acid,  acetic  acid,  carbonic  acid,  butyric  acid, 
and  oxalic  acid ;  all  except  the  hydrochloric  acid  are  the  result  of  de- 
composition. Some  articles  of  food  produce  these  different  acids  in 
considerable  quantities.  Thus  sugar  generates  large  amounts  of  lactic 
acid.  The  mode  of  detecting  these  acids,  and  of  establishing  whether 
the  extreme  acidity  is  due  to  excess  of  hydrochloric  acid  or  to  other 
acids,  as  tested  after  a  trial  meal,  has  been  above  explained.  In  ex- 
amining for  acids,  the  two  acids  of  greatest  value  to  determine  are 
hydrochloric  acid  and  lactic  acid.  In  determining  the  acidity  of  the 
stomach  contents  we  must  first  ascertain  the  whole  amount  of  acidity 
present  in  the  stomach  contents  after  the  trial  meal,  and  then  the  per- 
centage of  hydrochloric  acid. 

The  acids  which  are  created  in  the  stomach  may  give  rise  to  various 
disorders.  When  much  acid  is  present  it  occasions  a  sensation  of  heat 
which  extends  along  the  oesophagus.  This  "  heart-burn"  is  apt  to 
happen  in  paroxysms,  and  is  attended  with  a  feeling  of  constriction 
or  with  actual  pain  at  the  epigastrium.  It  simply  denotes  great  acidity, 
and  is  common"  in  gouty  persons.  It  probably  arises  from  the  action 
of  the  acid  contents  of  the  organ  on  the  sensitive  nerves  of  the  cardia 
and  of  the  oesophagus,  and  the  acid  is  mostly  owing  to  fermentative 
changes.  When  the  acidity  is  due  to  increase  of  hydrochloric  acid, 
from  excessive  acidity  or  quantity  of  the  gastric  juice,  it  is  the  result 
of  a  gastric  neurosis ;  there  may  be  acid  vomiting  coming  on  irre- 
spective of  food,  and  happening  in  the  night  or  during  the  early  morn- 
ing hours.  What  has  been  called  gastroxynsis  by  Rossbach  is  a  gastric 
neurosis  appearing  at  intervals  mostly  after  some  psychical  or  mental 
disturbance,  and  marked  by  extremely  acid  vomiting  and  headache, 
like  that  of  migraine. 

Flatulency. — The  gas  in  the  intestinal  canal  may  be  merely  air 
which  is  swallowed  ;  or  it  may  be  generated  from  imperfectly  digested 
food  ;  or  it  may  be  a  secretion  from  the  blood-vessels  of  the  part.  In 
those  who  suffer  from  indigestion  it  is  produced  in  the  last  two  ways, 
and  the  patient  complains  greatly  of  the  annoyance  it  occasions.  It 
causes  a  disgust  for  eating,  a  feeling  of  distention,  and  sometimes  actual 
pain.  By  interfering  with  the  downward  movements  of  the  diaphragm 
it  induces  a  sensation  of  constriction  in  the  chest,  shortened  breathing, 
palpitation  of  the  heart,  and  the  sleep  is  broken  by  uneasy  dreams. 

30 


478  MEDICAL  DIAGNOSIS. 

An  expulsion  of  the  gaseous  contents  of  the  stomach  by  the  mouth 
gives  rise  to  eructation,  or  belching.  The  belching  which  follows  the 
decomposition  of  food  has  sometimes  the  taste  and  the  odor  of  sul- 
phuretted hydrogen.  At  other  times  the  eructation  is  odorless,  because 
the  gases  formed  are  carbonic  acid,  or  hydrogen  or  nitrogen,  or  some 
of  their  compounds.  When  the  gas  results  from  fermentation  or  de- 
composition of  food,  it  frequently  coexists  with  acidity  occurring  only 
after  meals.  When  it  is  a  secretion  from  the  blood-vessels  it  happens 
in  an  empty  state  of  the  stomach,  and  is  often  relieved  by  avoiding 
too  long  intervals  between  the  meals.  As  a  cause  of  flatulence  and 
eructation  which  it  is  important  not  to  overlook  may  be  mentioned 
thoracic  aneurism.^  Marked  flatulency  is  often  only  a  form  of  gastric 
neurosis.     It  is  common  in  nervous  dyspepsia  and  in  hysteria. 

Nausea  and  Vomiting. — These  are  often  combined.  But  some- 
times there  is  persistent  nausea  without  vomiting ;  sometimes  vomit- 
ing occurs  without  any  or  with  but  slight  nausea.  Yet  they  are  both 
occasioned  in  much  the  same  way :  what  gives  rise  to  one  wiU  gener- 
ally give  rise  to  the  other. 

Vomiting  is  a  complex  act.  But  its  causes,  although  various,  may 
all  be  arranged  under  four  heads.  It  either  arises  from  an  irritation 
of  the  peripheral  extremities  of  the  nerves  which  supply  the  parts 
more  directly  concerned  in  the  act  itself,  such  as  the  stomach,  the  dia- 
phragm, and  the  oesophagus  ;  or  the  irritation  originates  in  the  centres 
from  which  these  nerves  spring,  and  is  referred  to  their  peripheries ; 
or  there  is  a  mechanical  obstruction  in  the  stomach  or  intestines ;  or 
the  vomiting  is  purely  sympathetic.  Under  the  first  head  belongs  the 
vomiting  observed  in  acute  or  chronic  inflammation  of  the  stomach,  in 
ulcer,  or  in  cancer ;  also  that  fohowing  a  debauch,  or  the  introduction 
of  irritating  substances  into  the  viscus.  Under  the  second  head  may 
be  ranged  the  vomiting  which  occurs  in  diseases  of  the  brain  ;  perhaps, 
also,  that  which  arises  in  morbid  states  of  the  blood,  as  in  uraemia. 
Under  the  third  head  we  may  class  the  vomiting  in  narrowing  of  the 
oesophagus  and  of  the  pyloric  or  cardiac  extremity  of  the  stomach,  in 
hour-glass  constriction  of  the  stomach,  and  in  obstructions  of  the 
intestine.  The  fourth  group  is  exemplified  by  the  vomiting  in  preg- 
nancy, in  wounds  of  the  extremities,  in  inflammation  of  the  perito- 
neum, of  the  intestines,  and  of  the  liver,  in  renal  calculus,  and  in 
irritation  of  the  fauces. 

Connected  thus  with  so  many  various  conditions,  the  act  of  vomit- 
ing, taken  by  itself,  is  of  little    diagnostic  value.      It  presupposes  a 


1  Walter  F.  Atlee,  Amer.  Journ.  Med.  Sci.,  July,  1869. 


DISEASES  OF  THE  STOMACH,  479 

certain  amount  of  irritation  existing  in  the  stomach,  or  reflected  to  it ; 
but  nothing  more.  As  it  is  alHecl  to  morbid  states  too  numerous  to 
be  here  examined  in  detail,  I  shall  content  myself  with  making 
general  statements  regarding  the  indications  to  be  drawn  from  it. 

When  vomiting  is  observed  in  a  person  previously  in  good  health, 
we  may  suspect  either  the  invasion  of  some  acute  malady,  or  that 
some  poisonous  substance  has  been  swallowed.  Again,  it  may  come 
on  suddenly  from  violent  mental  emotion.  When  everything  that  is 
taken  is  immediately  expelled,  the  difficulty  lies  in  the  oesophagus,  or 
at  the  cardiac  orifice  of  the  stomach,  or  in  an  extreme  irritability  of 
the  viscus  ;  and  this  irritability,  attended  as  it  often  is  with  unceasing 
nausea,  experience  proves  to  be  more  frequently  due  to  sympathetic 
excitement  of  the  organ  than  to  structural  gastric  disease.  But  speedy 
vomiting,  generally  without  preceding  nausea,  is  also  among  the  symp- 
toms of  visceral  hysteria.  I  have  known  it  associated  or  alternating 
with  extraordmary  flatulency. 

Nervous  vomiting  occurs  where  there  is  no  lesion  in  the  stomach 
or  irritation  of  food  as  the  cause.  It  is  mostly  due  to  reflected  irrita- 
tion of  the  nerve-centres  controlling  the  act  of  vomiting,  and  is  often 
found  in  disorders  of  the  uterus ;  or  arises  from  direct  irritation  of 
the  nerve-centres  in  affections  of  the  brain  and  cord.  It  is  common 
in  hysterical  subjects.  It  is  not  associated  with  nausea,  and  may  be 
of  long  duration.  It  is  sometimes  a  primary  gastric  neurosis,  and  as 
such  is  seen,  particularly  in  neurasthenics,  in  association  with  the 
condition  described  by  Kussmaul  as  "  peristaltic  unrest."  This  is  a 
very  annoying  symptom,  in  which  there  are  loud  borborygmi  and 
gurgling,  especially  after  eating.  The  functional  vomiting  of  hysterics 
presents  the  curious  feature  of  nothing  apparently  being  retained  on 
the  stomach,  yet  the  patient  remaining  fairly  well  nourished.  There 
is  no  nausea  with  the  vomiting.  Cases  of  the  kind  are  sometimes  met 
with  where  there  is  no  obvious  hysteria,  but  where  overwork  and 
anxiety  are  the  cause. 

As  regards  the  vomiting  which  is  brought  about  by  gastric  disor- 
ders, it  is  of  much  consequence  to  note  the  period  at  which  it  happens, 
whether  before  meals  or  after  meals,  and  how  long  afterwards.  In 
some  diseases,  such  as  ulcer  and  cancer,  it  rarely  occurs  except  when 
food  has  been  taken.  The  act  of  vomiting  then  affords  relief  from  the 
pain.  In  narrowing  of  the  pylorus,  it  takes  place  some  hours  after 
digestion  has  begun.  But,  as  vomiting  will  be  described  hereafter  in 
its  relations  to  the  individual  diseases  of  the  stomach,  we  shall  not 
dwell  on  what  will  be  more  fitly  discussed  elsewhere.  Yet  a  few  words 
on  the  characteristics  of  the  ejected  matter  can  hardly  be  omitted. 


4go  MEDICAL  DIAGNOSIS. 

The  nature  and  the  quantity  of  the  vomit  are.  of  course,  most " 
Yarious.     The  followmg  are  its  most  common  kinds  : 

Food  or  liquid,  mixed  with  sahva  and  some  mucus,  is  expelled 
when  the  stomach  is  very  irritable,  or  if  an  obstruction  exist  which 
renders  the  entrance  into  the  organ  difficult  or  impossible.  Half- 
digested  food,  in  a  state  of  acetous  fermentation  and  with  a  strongly- 
acid  reaction,  is  cast  out  when  there  is  deficiency  of  hydrochloric 
acid,  or  when  the  food  has  been  detained  for  a  long  time  ui  the 
stomach.  In  the  ejected*  matter  the  particles  of  food  may  be  rec- 
ognized;  but  when  the  food  has  been  kept  for  a  prolonged  period 
in  the  stomach,  or  when  it  has  passed  on  into  the  duodenum  and 
is  returned,  it  is  changed  into  an  apparently  homogeneous  mass. 
Examined  under  the  microscope,  the  structures  of  the  anmial  or 
vegetable  substances  partaken  of  can  even  then  be  detected.  Mixed 
with  muscular  fibre,  elastic  tissue,  starch-corpuscles,  and  vegetable 
cehs,  is  found  usually  a  quantity  of  oil-drops  and  fat-crystals.  The 
starch  cori^uscles  are  turned  blue  by  a  solution  of  iodine  and  iodide 
of  potassium. 

Sarcince  and  yeast  fungi  are  sometimes  discovered,  by  means  of 
the  microscope,  in  the  vomit.     These  organisms  are  associated  with 

the  process  of  fermentation,  and  are  generally 
■^^^'  '^'  attended   with    copious   vomiting.     They  are 

small  square  or  slightly  oblong  bodies,  divided 
into  sunilar  smaher  portions  by  cross-lines, 
and  each  portion  thus  formed  is  again  sub- 
divided ;    but   the   markings    of    the    smaller 


sauares  are  not  so  distinct  as  those  of  the 

Sarcinse  ventnculi.  ^ 

larger.     The  illustration  shows  a  mass  of  sar- 
cinse  found  m  the  vomit  of  a  patient  who  suffered  from  gastric  ulcer. 

Vomit  contauiing  sarcmge  is  always  indi.cative  of  structural  change 
in  the  stomach.  It  is  sometimes  found  in  chronic  gastritis  of  long 
standhig ;  or  in  connection  with  ulcer,  and  yet  oftener  with  cancer, 
and  especially  in  those  cases  m  which  the  narrowing  at  the  pyloric 
extremity  has  led  to  distention  of  the  organ  ;  indeed,  any  form  of 
dilatation,  or  a  condition  preventing  the  stomach  from  completely 
emptying  itself,  pre-eminently  gives  rise  to  it. 

Sarcina  vomit  has  an  acid  smell  and  reaction,  and  often  a  peculiar 
brownish  appearance.  After  standing,  it  becomes  covered  with  a 
dirty,  frothy  matter,  like  yeast.  A  solution  of  iodme  and  iodide  of 
potassium  turns  the  sarcinae  mahogany  brown  or  a  violet  hue ;  but 
it  is  by  the  microscope  that  their  presence  can  be  recognized  with 
greatest  certainty.    The  process  of  fermentation  attending  the  develop- 


DISEASES  OF  THE  STOMACH.  481 

ment  of  the  sarcinaB  occasions  heart-burn  and  extreme  flatulency,  and 
the  copious  vomiting  is  a  source  of  relief. 

Mucus  is  occasionally  ejected  in  large  quantities,  both  mixed  with 
food  and  pure.  In  chronic  gastritis,  and  in  the  milder  forms  of  acute  gas- 
tritis, the  mucous  membrane  is  covered  with  a  tenacious  secretion,  and 
a  considerable  amount  of  a  glairy  or  stringy  matter  is  expelled  by  the 
act  of  vomiting.  As  a  general  rule,  indeed,  it  may  be  stated  that,  when 
much  mucus  is  evacuated,  a  catarrhal  state  of  the  stomach  is  present, 

A  thin,  watery  fluid,  looking  much  like  saliva,  is  discharged  in  some 
cases  of  organic  disease  of  the  stomach,  as  well  as  in  functional 
derangement  of  the  organ  brought  on  by  eating  coarse  food.  Now 
and  then  it  is  met  with  in  pregnancy.  This  variety  of  vomiting  is 
known  as  pyrosis ;  popularly,  as  "water-brash."  It  may  be  attended 
with  a  burning  sensation  extending  to  the  fauces,  and  with  pain 
running  back  to  the  spine.  The  fluid  is  commonly  alkaline.  Frerichs 
found  that  it  possessed  the  power  of  converting  starch  into  sugar. 
It  is  mostly  regarded  as  being  formed  by  the  glands  at  the  lower  part 
of  the  oesophagus,  while  others  hold  that  it  is  the  saliva  which  has 
been  swallowed  and  accumulated  in  the  stomach. 

Bile  may  find  its  way  into  the  stomach,  and  be  expelled  by  the 
mouth,  imparting  to  the  vomit  a  greenish  or  yellowish  color  and  a 
very  bitter  taste.  The  occurrence  of  bUious  vomiting  is  commonly 
held  to  indicate  a  disease  of  the  liver,  or  that  the  patient  is  extremely 
*' bilious."  It  is  not  a  proof  of  either.  It  is  observed  when  there  is 
much  retching,  and  when  the  act  of  vomiting  is  protracted  and 
frequently  repeated,  and  is  chiefly  met  with  in  the  various  forms  of 
acute  gastritis,  and  on  the  invasion  of  some  acute  malady  which  gives 
rise  to  sympathetic  gastric  disturbance. 

Fecal  vomiting  never  depends  upon  a  disease  of  the  stomach. 
It  may  be  possibly  owing  to  a  fistulous  opening  between  the  colon 
and  the  stomach  ;  but  such  cases  are  extremely  rare.  Generally  it  is 
due  to  a  mechanical  obstruction  to  the  passage  of  faeces.  Occasion- 
ally it  happens  in  fevers  of  a  low  type,  or  in  peritonitis,  and  is  then, 
perhaps,  the  result  of  paralysis  of  a  portion  of  the  intestinal  tube, 
which  acts,  to  some  extent,  as  a  mechanical  obstruction.  The  matter 
that  is  ejected  has  the  odor  of  fseces  ;  but  it  is  of  less  firm  consistence, 
and  of  lighter  color,  because  it  is  the  contents  rather  of  the  small  than 
of  the  large  intestine.  Sometimes  it  is  perfectly  fluid.  In  fecal  vomit 
a  considerable  number  of  large  comma-like  bacilli  have  been  noticed.^ 

Pus  in  small  amount  is  sometimes  found  mixed  with  the  vomit  in 

^  Von  Jaksch,  Klinische  Diagnostik. 


482  MEDICAL  DIAGNOSIS. 

cases  of  large  ulcers  in  the  stomach,  simple  or  cancerous.  When  in 
quantities,  it  is  owing  to  an  abscess  in  the  neighborhood  of  the  viscus 
having  poured  its  contents  into  it.  Still,  pus  is  rarely  met  with  in  the 
matters  expelled.  And  the  same  can  be  said  of  other  substances  that 
find  their  way  into  the  stomach,  like  echinococcus  sacs  and  worms, 
and  masses  of'  false  membrane. 

Blood,  on  the  other  hand,  is  not  infrequently  vomited.  Having  de- 
scribed the  appearance  of  the  blood  when  it  comes  from  the  stomach, 
in  treating  of  the  diagnosis  of  hemorrhage  from  the  lungs,  I  shall, 
before  examining  into  the  circumstances  which  cause  a  haematemesis, 
merely  here  recall  the  fact  that  it  is  preceded  by  nausea  and  followed 
by  black  stools,  and  that  the  fluid  ejected  is  generally  black,  and  pre- 
sents an  acid  reaction. 

The  quantity  of  blood  lost  varies  greatly  ;  but  the  amount  vomited 
is  by  no  means  a  proof  of  the  amount  effused.  The  larger  portion 
may  pass  off  by  the  bowels,  giving  rise  to  peculiar  tarry  stools.  Nay, 
the  whole  may  be  voided  with  the  stools.  Chocolate-colored  material 
discharged  by  stool,  and  due  to  alkaline  fluids  acting  on  the  blood  after 
the  effect  of  acids,  is  held  to  be  a  distinguishing  trait  between  the 
blood  passing  by  the  intestines  after  a  gastric  hemorrhage  and  bleeding . 
from  the  bowel.^ 

Hemorrhage  from  the  stomach  is  variously  caused.  It  may  spring 
from  injury  to  the  organ,  or  from  disease  of  its  coat ;  it  may  be  vica- 
rious ;  it  may  be  the  consequence  of  disorder  elsewhere  than  in  the 
stomach,  as  of  a  mechanical  obstruction  in  the  portal  system ;  it  may 
depend  upon  an  altered  state  of  the  blood. 

In  the  hemorrhage  that  follows  blows  or  kicks  on  the  stomach,  an 
active  hypersemia  of  the  mucous  surface  is  occasioned,  which  leads  to 
the  extravasation  of  blood.  An  active  arterial  hypersemia  also  pre- 
cedes the  hemorrhage  that  sometimes  follows  the  swallowing  of  irri- 
tant poisons.  Of  organic  affections  of  the  stomach  only  cancer  and 
ulcer  are  apt  to  present  hemorrhage  as  a  prominent  symptom ;  and 
of  these,  again,  it  is  much  more  frequent  in  the  latter  than  in  the 
former.  The  blood  effused  may  be  so  slight  in  amount  as  to  escape 
detection  ;  and  this  is  especially  likely  to  happen  when  it  is  intimately 
admixed  with  food  or  with  bile.  Yet,  by  means  of  the  microscope, 
the  existence  of  blood-corpuscles  in  the  ejected  matter  can  be  always 
demonstrated.  The  fulness  of  the  vessels  may  be  associated  with 
degeneration  of  their  coats,  as,  for  instance,  in  amyloid  degeneration 
of  the  stomach. 

^  Bartholow,  Practice  of  Medicine. 


DISEASES  OF  THE   STOMACH.  483 

When  blood  has  been  detained  for  some  time  in  the  stomach,  and 
has  become  intimately  mingled  with  the  acid  contents  of  the  organ,  it 
loses  entirely  its  natural  appearance.  What  is  termed  "  coffee-ground 
vomit"  is  blood  thoroughly  intermixed  with  other  substances.  It  is 
the  result  of  a  comparatively  small  or  gradual  hemorrhage,  and  as  this 
is  the  kind  apt  to  happen  in  gastric  cancer,  it  is  common  in  this  affec- 
tion, though  by  no  means  limited  to  it. 

Vicarious  hemorrhage  from  the  stomach  is  not  infrequent,  and 
especigilly  frequent  is  that  which  takes  the  place  of  the  menses.  It  is 
not  dangerous.  The  blood  escapes  at  the  time  of  the  normal  dis- 
charge, and  while  the  bleeding  lasts  the  stomach  is  slightly  tender,  and 
the  digestion  impaired.  But  during  the  intervals  there  are  no  signs  of 
disturbance  of  the  functions  of  the  organ,  and  no  pain,  both  of  which 
are  points  of  importance  in  distinguishing  between  loss  of  blood  caused 
by  suppressed  menstruation  and  loss  of  blood  caused  by  disease  of  the 
stomach. 

Gastric  hemorrhage,  dependent  upon  a  state  of  passive  congestion 
brought  on  by  an  obstruction  to  the  flow  of  venous  blood,  is  occasion- 
ally seen  in  organic  affections  of  the  heart.  But  it  is  much  more 
common  as  the  result  of  embarrassment  of  the  portal  circulation  from 
tumors  or  from  affections  of  the  liver  and  spleen.  It  frequently  at- 
tends, therefore,  cirrhosis  and  enlargement  of  the  spleen,  and  is  often 
joined  to  intestinal  hemorrhage. 

In  gastric  hemorrhage  resulting  from  changes  in  the  blood  the  ves- 
sels themselves  are  toneless,  and  rupture  easily  or  offer  no  resistance 
to  their  altered  contents  escaping.  This  kind  of  hemorrhage  is  met 
with  in  scurvy,  in  typhus  fever,  and  in  yellow  fever. 

We  see  thus  that  blood  is  vomited  from  various  causes,  and  that 
merely  from  the  occurrence  of  haematemesis  we  can  determine  noth- 
ing definite  as  to  its  origin.  Yet  the  symptom — for  a  symptom  it 
always  is — is  of  serious  import,  and  when  taken  in  connection  with 
others  is  of  great  service  in  diagnosis.  We  ought,  in  chronic  cases, 
first  to  suspect  the  hemorrhage  to  be  due  to  some  organic  disease  of 
the  stomach  :  when  there  is  no  other  proof  of  a  structural  affection  of 
this  organ,  we  turn  to  the  liver,  spleen,  or  heart  for  its  explanation,  or 
examine  carefully  every  part  of  the  abdominal  cavity,  to  see  whether 
or  not  a  tumor  is  the  source  of  the  disorder.  If  occasioned  by  none 
of  these  conditions,  its  cause  lies  probably  in  altered  blood,  or  in  sup- 
pressed discharges.  The  history  of  the  case  is  indispensable  to  any 
induction. 

There  is,  however,  one  difficulty  present  in  all  instances  ;  and  that 
is,  to  tell  whether  the  ejected  blood  has  found  its  way  into  the  stomach 


484  MEDICAL  DIAGNOSIS. 

and  has  been  subsequently  expelled,  or  whether  the  hemorrhag'e  is 
really  gastric.  The  only  method  to  avoid  being  mistaken  is  to  scruti- 
nize closely  the  liistory  and  the  attending  phenomena.  Blood  may  be 
introduced  into  the  stomach  by  the  bursting  of  an  aneurism,  or  from 
an  ulcerating  pancreas ;  or  it  may  have  been  swallowed  during  an 
attack  of  epistaxis  or  of  hsemoptysis,  or  wilfully,  to  excite  sympathy  or 
to  escape  punishment.  A  strange  result  of  gastric  hemorrhage,  first 
noticed  by  Graefe,  is  double-sided  incuralDle  amaurosis.  In  some  cases 
atrophy  of  the  optic  nerves  has  been  found.  The  symptoms  and 
lesions  have  been  attributed  to  occlusion  of  retinal  vessels. 

To  return  to  the  more  special  symptoms  of  a  deranged  stomach. 

Merycism,  or  Rumination. — In  this  condition  food  that  has  been 
swalloAved  is  brought  up  mto  the  mouth,  sometimes  by  an  impulse  of 
the  will,  but  more  commonly  involuntarily,  and  remasticated  and 
again  swallowed.  Rumination  is  recognized  to  be  purely  a  neurosis, 
and  may  or  may  not  be  associated  -with  other  gastric  disorder. 

Regurgitation  of  fluid  or  partly  digested  food  may  take  place  in 
connection  with  a  relaxed  condition  of  the  cardiac  orifice  of  the 
stomach,  and,  if  obstinate,  may  lead  to  pronounced  derangement  of 
nutrition.  This  phenomenon  is  to  be  distinguished  from  a  similar 
occurrence  that  takes  place  when  the  oesophagus  is  the  seat  of  a  pouch 
or  diverticulum  that  empties  itself  from  time  to  time. 

Pain. — Pain  in  gastric  disorders  is  sometimes  slight,  at  other 
times  violent.  It  is  often  rather  a  feeling  of  soreness  than  actual 
suffering.  It  may  or  may  not  be  increased  by  pressure,  and  may 
be  augmented  or  relieved  by  the  taking  of  food.  If  persistent,  and 
accompanied  by  tenderness  at  the  epigastrium,  it  is  almost  always 
linked  to  a  morbid  state  of  the  tissues  of  the  viscus.  Uneasy  sensa- 
tions, on  the  other  hand,  also  happen  in  functional  derangement  of 
the  organ  while  the  food  is  being  digested,  and  may  be  even  attended 
wath  slight  tenderness  at  the  epigastrium.  As  a  rule,  pain  and  sore- 
ness dependent  on  organic  disease  may  be  distinguished  from  pain  and 
soreness  that  result  from  functional  disorder  by  noticing  the  time  at 
wdiich  they  take  place.  If  they  are  more  severe  soon  after  meals,  or 
when  the  stomach  is  full,  and  worse  after  a  heavy  meal  than  after  a 
light  one,  especially  of  a  bland  substance  like  mOk,  they  point  to  a  struc- 
tural affection.  If  they  occur  only  when  the  stomach  is  empty,  and 
are  relieved  by  food,  they  are  indicative  of  a  functional  derangement. 

Occasionally  the  stomach  is  the  seat  of  violent  paroxysms  of  pain. 
These  are  at  times  linked  to  a  chronic  organic  affection  ;  at  others  they 
are  apparently  connected  with  a  perfectly  sound  state  of  the  viscus,  and 
coexist  with  a  tendency  to  neuralgic  pains  all  over  the  body,  or  with 


DISEASES  OF  THE   STOMACH.  485 

hysteria  or  neurasthenia  ;  or  they  may  appear  as  tlie  gastric  crises  of 
locomotor  ataxia ;  at  others  they  are  brought  about  by  some  article  of 
food  which  the  stomach  does  not  tolerate  or  is  unable  to  digest.  The 
disorder  is  called  gastralgia,  or  gastrodynia  ;  it  is  due  to  a  neuralgia  of 
the  stomach.  When  the  predisposition  to  it  exists,  exposure  to  cold 
and  damp,  a  draught  of  cold  water  drunk  when  heated,  sudden  and 
violent  emotions,  or  a  collection  of  wind  in  the  alimentary  canal,  will 
bring  it  on.  The  predisposition  is  met  with  in  gouty  and  rheumatic 
persons,  and  in  those  who  are  debilitated, — in  women  who  are  anaemic, 
and  in  men  who  have  been  exposed  to  exhausting  influences.  Then 
we  also  And  the  gastralgia  interchanged  with  other  neuralgic  or  spas- 
modic affections,  giving  way  to  asthma  or  to  angina  pectoris,  or,  on  the 
other  hand,  occurring  in  their  place.  Clifford  Allbutt  and  others  have 
also  pointed  out  a  close  connection  between  gastralgia  and  aortic 
regurgitation. 

The  pain  varies  much  in  intensity :  it  is  usually  severe  and 
agonizing ;  but  it  is  not  permanent ;  intervals  of  rest  and  comfort 
succeed  to  the  paroxysms  of  distress.  During  a  violent  attack,  the 
skin  is  cold,  the  pulse  slow,  there  are  frequently  nausea,  vomiting, 
sometimes  fainting,  and  often  sensations  of  utter  prostration.  The 
seat  of  the  pain  is  in  the  epigastrium,  immediately  beneath  the  ensi- 
form  cartilage,  but  it  radiates  both  upward  and  downward,  or  to  the 
sides.  The  patient  feels  as  if  the  coats  of  the  stomach  were  being 
violently  drawn  together,  or  rent  asunder,  or  rapidly  pierced  by  a 
sharp  instrument.  It  is  sometimes  relieved  by  the  recumbent  position 
and  by  external  pressure.  But  relief  depends  much  on  the  condition 
with  which  the  pain  is  associated.  If  it  be  connected  with  a  chronic 
gastritis  or  an  ulceration,  or  a  cancer,  pressure  aggravates  rather  than 
alleviates  it.  There  is  sometimes  sensitiveness  to  the  touch  in  purely 
nervous  gastralgia,  and  over  a  considerable  part  of  the  stomach ;  or 
slight  pressure  may  augment  the  pain,  but  firmly  compressing  the  pit 
of  the  stomach  will  diminish  it. 

It  is  always  important  to  discriminate  between  the  cases  of  gas- 
tralgia that  may  be  viewed  as  pure  neuroses  and  those  in  which  the 
paroxysms  of  pain  are  combined  with  a  chronic  lesion.  We  infer  that 
we  have  to  deal  with  instances  of  the  former,  when  the  attacks  occur 
in  those  whose  impoverished  blood  or  enfeebled  health  predisposes  to 
neuralgia,  and  especially  if  they  happen  in  Avomen  laboring  under  dis- 
orders of  the  uterus  or  of  menstruation,  and  the  attacks  increase  about 
the  menstrual  period,  or  in  persons  who  suffer  from  neuralgic  pains  in 
other  parts  of  the  body.  But  the  broadest  line  of  distinction  is  drawn 
by  the  state  of  the  digestive  apparatus  during  the  intervals.     The  dis- 


486  MEDICAL  DIAGNOSIS. 

ordered  digestion,  tte  pain  after  eating,  the  persistent  tenderness  at 
the  epigastrium,  the  nausea  and  vomiting,  and  the  otlier  symptoms 
common  in  morbid  alterations  of  the  coats  of  the  stomacli,  are  not 
seen  in  pure  gastralgia.  A  sign  generally  trustworthy  is  the  alleviation 
following  the  taking  of  food,  for  which,  in  truth,  there  may  be  a 
craving ;  and  occasionally  cases  of  gastralgia  are  met  with  in  which 
the  pain  occurs  early  in  the  mornings,  and  is  very  distressing,  but  is 
almost  immediately  eased  by  a  hearty  breakfast. 

Gastralgia  is  common  where  there  is  an  excess  of  hydrochloric 
acid  in  the  gastric  juice,  though  Leube  states  that  test  meals  show,  as 
a  rule,  but  little  change.  The  form  of  gastralgia  which  is  produced  by 
some  article  of  food  that  disagrees  with  the  individual  is  readily  dis- 
tinguished from  the  other  varieties  by  observing  it  to  be  transient,  and 
by  noting  its  cause.  The  indigestible  substance  undergoes  fermenta- 
tion in  the  stomach,  and  acidity,  flatulent  distention,  and  nausea  attend 
the  pain,  which  ceases  when  the  extreme  acidity  is  neutralized  by  an 
alkali,  or  the  offending  matter  is  ejected  and  the  gas  expelled. 

The  remarks  just  made  apply  also,  in  the  main,  to  other  manifesta- 
tions of  perverted  innervation  of  the  stomach,  such  as  hyper£esthesia, 
with  or  without  persistent  vomiting, — forms  happening  usually  in  weak 
or  hysterical  persons,  or  where  menstruation  is  disordered, — but  which 
in  the  present  state  of  our  knowledge  are  still  conveniently  classed 
with  gastralgia  as  forms  of  gastric  neuroses. 

The  nervous  iilaments,  the  irritation  of  which  occasions  pain  in  the 
stomach,  whether  paroxysmal  or  not,  belong  to  the  vagus  ;  sometimes, 
perhaps,  the  distress  originates  in  the  branches  of  the  sympathetic 
that  supply  the  organ.  But  we  must  be  careful  not  to  ascribe  the  seat 
of  every  pain  which  is  felt  between  the  umbilicus  and  sternum,  or  re- 
ferred there,  to  the  stomach.  Diseases  of  the  pleura,  of  the  heart  and 
its  covering,  affections  of  the  intercostal  nerves,  abscess  of  the  liver, 
intestinal  disorders,  rheumatism  of  the  abdominal  muscles,  may  give 
rise  to  pain  in  the  epigastric  region.  Spasmodic  pain  like  that  of  gas- 
tralgia may  be  caused  by  intercostal  neuralgia,  by  intestinal  colic,  by 
disorganization  of  the  tissue  of  the  kidney  or  of  the  pancreas,  and  by 
the  passage  of  gall-stones  or  of  renal  or  pancreatic  calculi.  The 
strictly  paroxysmal  character  of  the  pain,  its  seat  in  the  region  of  the 
heart  or  shooting  down  the  left  arm,  the  agitation  and  distress,  the 
affected  breathing,  the  severity  of  the  symptoms,  distinguish  gastralgia 
from  angina  j:)ecto7-is,  and  even  pseudo-anginas  partake  of  the  graver 
character  of  the  disease.  In  the  passage  of  gall-stones  the  great 
severity  of  the  pain,  the  attending  nausea  and  vomiting,  the  subse- 
ciuent  jaundice,  are  most  significant.     But  there  are  puzzling  cases ; 


DISEASES  OF  THE   STOMACH.  487 

and  what  makes  the  diagnosis  more  difficult  is  that  in  persons  affected 
with  gall-stones  gastralgia  is  not  uncommon,  and,  on  the  otlier  hand, 
an  attack  of  biHary  cohc  may  seem  to  be,  or  is,  started  by  one  of 
indigestion.  The  locahzed  spots  of  tenderness,  in  the  course  of  the 
affected  intercostal  nerve,  distinguish  doubtful  cases  of  intercostal 
neuralgia  from  gastralgia.  Then,  too,  a  galvanic  current  removes  or 
greatly  lessens  the  pam  of  the  former.  The  great  safeguard  always 
against  error  is  to  bear  in  mind  that  painful  complaints  of  the  stomach 
may  be  mistaken  for  those  enumerated,  and  to  ascertain  carefully,  in 
cases  of  epigastric  distress,  that  there  is  no  cause  beyond  the  stomach 
to  account  for  it.  The  nearer,  in  many  instances,  the  pain  is  to  the 
median  line,  or,  should  it  occupy  this,  the  more  fixed  and  confined  to 
a  small  spot,  the  greater  is  the  probability  of  its  being  dependent 
upon  gastric  disease  ;  and  pain  of  the  character  alluded  to  is  generally 
indicative  of  serious  malady. 

Pam  is  the  last  of  the  symptoms  directly  referable  to  the  derange- 
ment of  the  viscus  itself  to  which  we  shall  advert.  But  when  the 
stomach  is  disordered,  other  organs  also  suffer,  either  through  sym- 
pathy, or  because  the  irritation  is  transmitted  to  them.  The  bowels 
are  usually  in  a  sluggish  condition ;  it  is  commonly  only  when  the  gas- 
tric acidity  is  extreme  that  they  are  relaxed.  The  viscera  within  the 
chest  are  frequently  disturbed.  The  patient  is  annoyed  by  palpitation 
and  shortness  of  breath  after  meals  ;  and  as  he  feels  the  agitation  of 
his  heart,  and  finds  that  always,  after  he  has  eaten,  his  face  is  flushed, 
the  palms  of  his  hands  are  hot,  and  his  temporal  arteries  throbbing, 
he  is  apt  to  fancy  himself  labormg  under  a  serious  cardiac  affection. 
A  dry  cough,  also,  is  a  not  unusual  concomitant ;  but  a  cough  may 
be  the  result  of  coexisting  catarrh  of  the  bronchial  mucous  membrane, 
or  of  disease  of  the  lung-structure  ;  and  sometimes  the  affection  of  the 
lungs  precedes  that  of  the  stomach.  Again,  we  may  have  an  organic 
disease  of  the  heart  leading  to  the  gastric  symptoms. 

So,  too,  with  the  kidneys.  They  may  be  irritated  by  the  crude 
material  which  has  made  its  way  into  the  blood,  and  which  they  are 
called  upon  to  excrete.  The  urine  often  contains  various  abnormal 
constituents,  especially  quantities  of  urates  and  oxalates.  But,  on  the 
other  hand,  a  morbid  state  of  the  urine  may  precede  the  derangement 
of  the  stomach,  and  the  indigestion  be  the  secondary  rather  than  the 
primary  ailment.  Indeed,  we  must  never  be  too  hasty  in  concluding, 
when  a  disordered  stomach  is  associated  with  diseases  of  other 
viscera,  that  it  is  their  cause ;  it  may  exist  as  their  consequence. 
Diseases  of  the  liver  and  intestines  are  especially  prone  to  induce  a 
gastric  affection. 


488  MEDICAL   DIAGNOSIS. 

One  of  the  worst  results  of  a  disordered  digestion  is  the  state  of 
mind  it  produces.  It  occasions  listlessness  and  a  disposition  to  look 
at  all  events  in  a  gloomy  light,  and  sometimes  brings  on  inveterate 
hypochondriasis.  Aretseus  ascrilDed  to  the  stomach  as  its  primary 
power  that  it  acted  as  the  president  of  pleasure  and  of  disgust,  "  being, 
from  the  sympathy  of  the  soul,  an  important  neighbor  to  the  heart  for 
imparting  good  or  bad  spirits."  Now,  although  no  one  at  present 
would  agree  with  this  physiology,  who  will  deny  that  there  is  in  the 
remark  a  germ  of  truth  ?  But  here,  agam,  we  must  be  careful  not  to 
confound  cause  with  effect ;  for  want  of  activity  or  a  distressed  state 
of  mind  may  seriously  impair  the  appetite  and  subvert  the  normal 
action  of  the  viscus.. 

When  the  nervous  symptoms  are  marked,  the  disorder  is  often 
called  nervous  dyspejisia.  In  this,  while  the  gastric  symptoms  may  be 
light,  we  may  also  have  the  gastric  neurosis  leading  to  extreme 
acidity  of  the  gastric  juice,  to  bad  taste  in  the  mouth,  increased  sali- 
vation, perverted  appetite,  to  eructations,  to  flatulency.  There  may 
be  sensations  of  distress  and  uneasiness  during  the  digestive  act,  and 
general  sensitiveness  in  the  epigastric  region,  but  the  gastric  motility, 
contrary  to  what  might  be  supposed,  is  not  impaired,  and  the  trial 
meals  are  digested  in  their  usual  time.  There  is  not  always  increased 
acidity  of  the  gastric  juice.  The  hydrochloric  acid  may  be  normal  or 
diminished  in  amount.  In  .all  forms  there  are  uneasy  feelings  after 
meals  and  great  nervousness.  Headache,  general  lassitude,  low 
spirits,  at  times  vertigo  and  palpitation,  are  complained  of.  Nervous 
dyspepsia  is  common  in  neurasthenics  and  in  hysterics.  The  exact 
state  of  the  stomach  that  coexists  can  be  determined  only  by  chemical 
investigation  of  the  gastric  secretion.  Leube^  maintains  that  the 
nervous  symptoms  are  induced,  because  the  nervous  system  itself  is 
in  a  very  irritable  state,  and  produces  morbid  digestion.  Viewed  in 
this  light,  nervous  dyspepsia  is  a  neurosis,  and  it  is  explained  how  it 
may  become  complicated  with  other  gastric  neuroses,  such  as  gas- 
tralgia.  But,  however  produced,  its  manifestations  are  evoked  by  the 
digestive  act. 

In  the  sketch  just  finished  of  the  symptoms  encountered  in  gastric 
disorders,  no  attempt  has  been  made  to  separate  strictly  the  signs 
which  belong  particularly  to  alteration  of  its  coats  from  those  Avhich 
occur  in  mere  derangement  of  its  functions, — in  other  words,  I  have 
not  tried  to  dissociate  the  symptoms  of  so-called  "  dyspepsia"  from 
those  of  actual  lesions.     And  this  for  two  reasons  :  in  the  first  place, 

^  Diaanose  der  inneren  Krankheiten,  1898,  vol.  i. 


DISEASES  OF  THE  STOMACH.  489 

the  most  palpable  indications  of  organic  disease  of  the  stomach  are 
those  of  disordered  function ;  and  secondly,  there  are  no  symptoms 
which  belong  exclusively  to  functional  indigestion.  Nor  is  it  possible 
to  present  anything  like  a  complete  picture  of  merely  functional,  or, 
as  it  is  still  called  by  some,  atonic  dyspepsia  ;  the  combinations  are  too 
infinitely  varied. 

The  stomach  may  be  the  seat  of  various  neurotic  disturbances, 
some  of  which  have  already  been  discussed.  Its  motor  activity  may 
be  deranged  in  the  direction  of  either  excess  or  deficiency,  and  result- 
ing, on  the  one  hand,  in  premature  propulsion  of  the  chyme  into  the 
intestine,  in  the  development  of  borborygmi  and  gurgling  or  of  eructa- 
tions, in  regurgitation  or  vomiting  of  food,  in  rumination  or  merycism, 
in  spasm  of  cardia  or  pylorus  ;  and,  on  the  other  hand,  in  atony  or 
insufficiency  of  the  cardia  or  the  pylorus.  Secretory  activity  may 
undergo  quantitative  or  qualitative  alteration.  Finally,  there  may 
result  a  condition  of  hyperaesthesia  or  gastralgia,  or  abnormalities  of 
appetite. 

Diseases  of  the  Storaach  in  which  Pain  and  Soreness  at  the 
Epigastrium,  and  Vomiting,  occur. 

After  what  has  been  premised,  it  is  obvious  that  the  structural  dis- 
eases of  the  stomach  present  but  few  symptoms  that  can  be  regarded 
as  at  all  characteristic.  Indeed,  the  only  ones  which  can  lay  any  claim 
to  be  so  considered — and  we  have  already  seen  that  this  claim  is  not 
always  valid — are  pain  and  soreness  at  the  epigastrium,  and  vomiting. 
We  may,  then,  take  these  symptoms  as  a  starting-point  in  diagnosis, 
and  describe  the  individual  organic  affections  in  which  they  chiefly 
occur,  speaking  first  of  the  acute. 

Acute  Gastritis. — Inflammation  of  the  stomach  may  be  of  vary- 
ing degree  and  extent.  It  may  involve  only  the  mucous  coat,  or  the 
other  tunics  as  well.  The  condition  arises  most  commonly  from  the 
ingestion  of  food  improper  in  quantity  or  in  quality.  Aggravated 
forms  of  the  disorder  may  result  from  the  introduction  into  the  stom- 
ach of  poisons,  such  as  alcohol,  the  mineral  acids,  caustic  alkalies,  or 
other  corrosive  substances.  The  presence  of  low  forms  of  vegetalDle 
life  may  be  an  exciting  cause,  and  sometimes  the  affection  is  part  of  a 
more  general  process,  as  of  diphtheria,  pneumonia,  typhoid  fever, 
smallpox,  and  rheumatism  or  gout.  In  rare  instances  the  disease  is 
phlegmonous  or  suppurative.  The  severity  of  the  symptoms  varies 
with  the  character  and  intensity  of  the  morbid  changes.  There  may 
be  merely  redness  and  thickening  of  the  mucous  membrane,  with  in- 
filtration of  the  other  coats  of  the  stomach  ;  or  there  may  be  desqua- 


490  MEDICAL  DIAGNOSIS. 

mation,  or  the  formation  of  false  membrane  ;  or,  finally,  suppuration, 
necrosis,  and  ulceration.  Among  the  usual  symptoms  are  anorexia, 
nausea,  vomiting,  pain  in  swallowing,  epigastric  distress  and  burning, 
with  tenderness  on  pressure,  usually  diarrhoea,  though  there  may  be 
constipation.  Thirst,  headache,  and  vertigo  also  are  common,  and 
we  may  find  elevation  of  temperature,  generally  not  over  102°,  with 
acceleration  of  pulse,  and  hiccough,  and  increased  frequency  of  respi- 
ration. In  severe  cases,  symptoms  of  collapse  are  met  with.  The 
milder  cases  terminate  in  recovery,  or  pass  into  chronic  gastric  catarrh. 
The  more  severe  cases  may  lead  to  ulceration  or  to  perforation  or  to 
rupture  of  the  stomach,  to  hemorrhage,  or  to  cicatricial  narrowing. 
In  phlegmonous  gastritis,  of  which  diffuse  inflammation  of  the  stomach 
wall  with  purulent  infiltration  is  the  more  common  form,  there  is  sud- 
den onset  as  well  as  a  sense  of  burning  and  violent  epigastric  pain,  and 
vomiting,  tenderness,  and  a  feeling  of  resistance  in  the  epigastric  re- 
gion, and  fever.  Shght  jaundice  may  also  be  present,  and  bilious 
vomitmg  ;  the  vomited  matter  may  contain  pus.  Peritonitis  and  signs 
of  collapse  are  apt  to  follow.^  The  disease  is  generally  primary  and 
the  infection  direct,  but  it  may  be  secondary  or  metastatic.  There 
are  very  severe  cases  of  ordinary  acute  gastritis,  mvolving  also  the 
muscular  coat,  which  are  undistinguishable  except  by  the  absence  of 
peritonitis  and  the  fact  that  they  may  recover.  I  have  seen  such 
instances.  Membranous  gastritis,  a  form  of  gastritis  more  common 
in  children  than  in  adults,  is  not  to  be  recognized  from  any  other 
kind  of  severe  gastritis,  unless  shreds  of  membrane  and  casts  are 
vomited. 

A  mild  gastritis  is  very  commonly  brought  on  by  a  debauch  or  by 
the  introduction  of  irritating  articles  of  diet  into  the  stomach.  These 
cases  are  classed  as  acute  gastric  catarrh,  and  are  popularly  known 
as  severe  attacks  of  indigestion  ;  that  they  are  owing  to  an  mflam- 
matory  state  of  the  mucous  membrane  was  proved  by  the  ocular 
demonstration  Beaumont  had  of  the  process  in  the  person  of  Alexis 
St.  Martin.  There  is  some  tenderness  at  the  epigastrium ;  nausea ; 
vomiting ;  constipation,  or  sometimes  diarrhoea ;  a  coated  tongue,  and 
headache. 

Another  common  and  kindred  kind  of  mild  inflammation  of  the 
stomach  or  acute  gastric  catarrh  is  that  usually  called  a  '*  bilious  at- 
tack." The  French  designate  it  expressively  as  embarras  gastrique. 
It  is  a  catarrhal  affection,  and  may  be  associated  with  catarrh  of  other 

^  See  an  excellent  analysis  of  the  recorded  cases  by  Leith,  in  the  Edinburgh 
Hospital  Reports,  vol.  iv.,  1896. 


DISEASES  OF  THE   STOMACH.  49I 

mucous  membranes.  It  may  come  on  from  indigestible  food,  or  after 
cold  and  exposure  ;  it  sometimes  occurs  in  epidemics.  The  symptoms 
are  those  already  detailed.  There  is  nausea,  and  frequently  bile  is 
vomited.  We  do  not  usually  observe  much  pain  in  the  epigastrium  ; 
but  rather  a  feeling  of  uneasiness,  and  a  slight  soreness  to  the  touch. 
The  urine  is  dark  and  deposits  urates;  the  tongue  is  much  coated; 
there  is  thirst,  with  generally  a  moderate  or  slight  fever,  which  exacer- 
bates at  night,  and  is  of  remittent  type,  and  there  may  be  a  yellowish 
tinge  of  the  conjunctivae.  In  children  acute  gastric  catarrh  may  be- 
come complicated  with  convulsions,  or  with  symptoms  simulating  those 
of  meningitis. 

A  form  of  gastritis  is  described  which  occurs  in  very  young  chil- 
dren and  leads  to  softening  of  the  mucous  lining  of  the  stomach,  a 
gastromalacia.  This  softening  is  most  likely  a  post-mortem  change 
due  to  the  action  of  the  gastric  juice,  and  especially  met  with  in  the 
subjects  of  acute  gastric  catarrh.  Kundrat  has  called  attention  to  the 
occurrence  of  gastric  softening  with  vomiting  of  blood  in  the  brain 
affections  of  children,  especially  in  tubercular  meningitis. 

* 

Chronic  Diseases  attended  with  Pain,  Epigastric  Tenderness,  and 

Vomiting. 

The  chronic  diseases  of  the  stomach,  like  the  acute,  may  be  con- 
sidered in  accordance  with  the  pain,  the  soreness  at  the  epigastrium, 
and  the  vomiting  that  attend  them.  At  all  events,  they  are  the 
symptoms  common  to  the  chronic  diseases  which  are  susceptible  of 
accurate  diagnosis.  In  these  chronic  diseases  vomiting  is  found  to  be 
a  symptom  of  greater  diagnostic  value  than  in  the  acute, — not  the 
act  itself,  but  the  appearances  of  the  ejected  matter.  Further,  the 
phenomena  of  dyspepsia  stand  forth  much  more  conspicuously. 

Chronic  Gastritis. — In  chronic  inflammation  of  the  mucous 
membrane,  or  chronic  gastric  catarrh,  the  symptoms  of  indigestion 
are  persistent  and  manifold.  They  vary  somewhat  according  to  the 
extent  of  the  mucous  surface  involved  and  the  amount  of  mucus  and 
epithelium  which  accumulates  on  it,  and  also  according  to  the  healthy 
or  wasted  state  of  the  gastric  glands.  Generally  there  is  a  sensation  of 
discomfort,  of  weight,  and  of  soreness  at  the  pit  of  the  stomach,  ag- 
gravated by  food ;  the  part  is  also  tender  to  the  touch.  Sometimes, 
even  when  the  stomach  is  empty,  a  burning  at  the  epigastrium  and  an 
inward  fever  are  complained  of.  The  appetite  is  impaired  or  capricious. 
Fermentation,  heart-burn,  and  flatulency  frequently  attend  the  slow 
digestion  of  the  food ;  the  tongue  is  usually  heavily  coated ;  it  may, 
however,  be  clean.     The  bowels  are  constipated.     The  urine  contains 


492  MEDICAL   DIAGNOSIS. 

an  excess  of  urates  or  of  phosphates,  or  exhibits  crystals  of  oxalate  of 
lime.  The  patient's  circulation  is  languid ;  he  suffers  from  chilliness  ; 
his  spirits  are  depressed.  Not  infrequently  he  is  annoyed  by  thirst, 
and  vomits,  after  meals,  the  half-digested  food  mixed  with  strings  of 
mucus.  But  the  vomiting  may  also  take  place  when  the  stomach  is 
empty,  and  the  ejected  matter  is  then  fluid  and  colorless.  Drunkards 
who  suffer  from  chronic  gastritis  often  throw  up  a  quantity  of  glairy 
fluid  on  rising  in  the  morning.  A  colorless  vomit,  joined  to  symp- 
toms of  long-continued  indigestion,  is  very  characteristic  of  chronic 
gastritis. 

The  gastric  contents  removed  after  a  trial  meal  show  a  diminution 
in  the  amount  of  hydrochloric  acid  present,  usually  in  the  total  acidity 
also,  and  in  the  activity  of  the  digestive  ferments ;  still,  hydrochloric 
acid  is  generally  present.  Absorption  from  the  stomach  is  retarded, 
although  gastric  motility  is  little  if  at  all  impaired.  The  fasting 
stomach  may  be  empty  or  contain  mucus. 

Chronic  gastric  catarrh  may  involve  the  mucous  membrane  or  also 
the  other  coats  of  the  stomach.  The  mucosa  may  be  thickened  or  it 
may  be  thinned ;  it  may  be  the  seat  of  erosions.  The  glandular 
structure  may  undergo  varying  degrees  of  atrophy.  All  of  the  coats 
of  the  stomach  may  eventually  become  sclerotic.  When  atrophy  of 
the  gastric  tubules  has  taken  place  there  is  complete  absence  of 
hydrochloric  acid  and  of  the  digestive  ferments. 

Thus,  then,  the  results  of  chemical  examination  of  the  removed 
gastric  contents,  the  character  of  the  vomit  occasionally,  more  fre- 
quently the  coated  tongue,  the  distress  after  eating,  the  soreness  at 
the  epigastrium,  and  the  persistency  of  the  symptoms,  distinguish  the 
dyspepsia  of  chronic  inflammation  of  the  stomach  from  that  which  is 
purely  functional. 

The  causes  of  the  malady  are  at  times  obscure.  It  certainly  can- 
not be  traced  often  to  an  antecedent  acute  attack,  although  those  who 
suffer  from  the  chronic  disorder  are  particularly  prone  to  acute  ex- 
acerbations. It  is  more  common  in  persons  over  than  in  those  under 
forty  years  of  age.  It  is  especially  common  in  gourmands  and  drunk- 
ards, and  in  those  who  live  on  coarse  food  or  who  eat  irregularly. 
It  is  often  found  conjoined  with  chronic  bronchitis,  with  anaemia,  with 
Bright's  disease,  mth  tubercular  disease  of  the  lungs,  with  gout,  and 
with  diabetes.  Passive  congestion  undoubtedly  acts  as  a  predisposing 
element,  and  thus  originates  the  chronic  gastric  catarrh  met  with  in 
affections  of  the  heart  and  of  the  liver. 

Chronic  gastritis  is  frequently  associated  with  ulcers  in  the  organ 
or  with  cancer,  and  many  of  the  symptoms  of  these  disorders  are 


DISEASES  OF  THE  STOMACH.  493 

clearly  attributable  to  it.  Let  us  inquire  whether  there  are  any 
special  symptoms  to  inform  us  that  something  more  dangerous  than 
chronic  inflammation  of  the  mucous  membrane  of  the  stomach 
exists. 

G-astric  Ulcer. — Ulcer  of  the  stomach  is  a  disease  comparatively 
rare  in  this  country ;  but  it  is  not  so  in  some  parts  of  the  Continent 
of  Europe  and  in  England.  It  seems  to  be  more  common  in  northern 
than  in  southern  climates.  The  affection  is  essentially  dependent 
upon  disturbance  of  the  normal  relation  between  the  gastric  secretion 
and  the  circulating  blood,  in  that  the  one  is  unduly  active  and  the  other 
is  deteriorated  in  quality.  It  is  more  common  in  females  than  in  males, 
and  between  twenty  and  forty  years  of  age  than  at  any  other  period. 
It  is  k  generally  associated  with  anaemia,  or  follows  chronic  gastric 
catarrh,  or  embolic  plugging  of  small  arterial  twigs,  or  other  disturb- 
ances of  the  circulation  in  the  gastric  mucous  membrane.  Amyloid 
degeneration  of  the  finer  vessels,  too,  occasions  these  perforating 
ulcers.  The  acid  gastric  juice  acts  readily  and  destructively  on  the 
weakened  tissues.  Rarely,  gastric  ulceration  is  due  to  tuberculosis 
and  to  syphilis. 

The  ulcer  or  ulcers,  for  there  are  sometimes  several  present,  are 
seated  usually  on  the  posterior  wall  of  the  stomach,  in  or  near  the 
lesser  curvature  and  towards  the  pyloric  extremity.  The  great  danger 
arises  from  perforation  of  the  coats  and  subsequent  peritonitis.  But 
the  ulceration  may  prove  fatal  by  opening  a  large  blood-vessel.  Again, 
the  formation  of  a  gastro-colic  or  a  gastro-pulmonary  fistula  may  lead 
to  death ;  or  the  protracted  suffering  and  excessive  vomiting  may 
gradually  exhaust  the  vital  energies.  On  the  other  hand,  the  ulcers 
may  heal  by  cicatrization ;  and  this,  William  Brinton  tells  us,  takes 
place  in  about  half  the  instances.  They  may  thus  form  tumor-like 
masses,  or  when  situated  at  the  pylorus,  they  may  cause  obstruction 
to  the  passage  of  the  chyme  into  the  duodenum.  Perforation,  Welch 
states,  happens  in  about  six  and  a  half  per  cent,  of  all  cases.  Recur- 
rence of  the  gastric  ulcer  is  not  uncommon. 

In  cases  which  may  be  regarded  as  typical,  the  malady  is  announced 
by  symptoms  exactly  like  those  witnessed  in  chronic  gastritis, — the 
same  uneasiness  and  pain  at  the  epigastrium,  and  occasional  nausea 
and  vomiting  of  food,  or  of  a  watery  fluid.  Perforation  may  at  this 
early  stage  of  the  disease  most  unexpectedly  cut  short  the  patient's 
life.  Should  perforation  not  take  place,  hemorrhage  from  the 
stomach,  with  emaciation  and  anaemia,  next  appears.  In  this  way 
the  disease  usually  continues  for  months  or  years,  the  symptoms 
remitting  from  time  to  time,  and  showing  singular  variations  in  their 

31 


494  MEDICAL  DIAGNOSIS. 

severity.  Welch  ^  states  the  averag'e  duration  of  gastric  ulcer  to  be 
from  three  to  five  years.     The  majority  of  the  cases  recover. 

Of  the  symptoms,  pain  and  vomiting  are  the  most  cliaracteristic. 
Pain  is  rarely  absent ;  never,  perhaps,  except  in  cases  which  run  a 
rapid  course.  It  is  generally  a  continuous  dull  feeling  ;  sometimes  a 
burning,  at  other  times  a  gnawing  sensation.  As  a  rule,  it  is  rendered 
more  acute  within  a  quarter  of  an  hour  after  eating,  and  remains  so 
as  long  as  food  occupies  the  stomach.  Its  situation  is  commonly  in  the 
middle  of  the  epigastric  region,  and  there  it  continues  strictly  limited. 
At  this  point,  too,  there  is  localized  soreness,  or  even  great  tender- 
ness to  the  touch.  Sometimes  the  pain  is  seated  behind  the  ensiform 
cartilage,  or  is  referred  to  the  right  or  to  the  left  hypochondrium.  It 
is  often  associated  with  a  gnawing  pain  in  the  lower  dorsal  vertebrae, 
wdiich  may  shoot  between  the  scapulee  or  down  the  spine  ;  but  the 
dorsal  pain,  like  the  epigastric,  is,  on  the  whole,  very  fixed,  radiates 
but  little,  and  is  most  severe  when  the  ulcer  is  on  the  posterior  sur- 
face. Besides  this  continued  feeling  of  distress,  there  occur  violent 
paroxysms  of  pain,  which  may  last  for  several  hours ;  nay,  with 
trilling  intermissions,  for  days.  They  sometimes  come  on  suddenly 
when  the  viscus  is  empty,  but  are  aggravated  by  pressure  or  by  food  ; 
and,  in  fact,  they  are  often  thus  induced.  The  patient  refers  the  suf- 
fering chiefly  to  the  pit  of  the  stomach,  or  to.  the  dorsal  vertebrae.  He 
is  apt  to  seek  the  recumbent  posture  for  its  relief.  Yet  it  is  remarka- 
ble that  there  are  at  times  long  intervals  during  which  all  pain,  whether 
paroxysmal  or  not,  ceases,  and  during  which  food  can  be  taken  with- 
out inconvenience.  The  acidity  of  the  urine  is  diminished ;  the  reac- 
tion may  even  be  alkaline  ;  the  chlorides  are  diminished  or  absent. 

The  peculiarities  the  pain  exhibits  form,  on  the  whole,  the  most 
distinctive  symptom  of  gastric  ulceration.  The  paroxysms  just  spoken 
of  may  be  mistaken  for  a  purely  nervous  gastralgia.  Indeed,  when 
it  is  considered  that  both  disorders  are  specially  apt  to  occur  in  anaemic 
women,  and  in  those  whose  menstrual  functions  are  deranged,  it 
becomes  apparent  how  easily  this  mistake  may  be  committed.  The 
soreness  at  the  epigastrium ;  the  persistent  symptoms  of  indigestion ; 
the  excess  of  hydrochloric  acid  in  the  gastric  juice ;  the  increase  of 
pain  after  meals, — constitute,  in  a  diagnostic  point  of  view,  the  safe- 
guard against  error.  To  these  might  be  added  the  vomiting  of  blood, 
were  it  not  that  vicarious  hemorrhages  are  not  at  all  unlikely  to  take 
place  in  young  women  who  are  troubled  with  amenorrhoea.  This  is, 
in  truth,  a  matter  having  a  close  connection  with  the  diagnosis  of 

^  Pepper's  System  of  Practical  Medicine,  article  "Simple  Ulcer  of  the  Stomach." 


DISEASES  OF  THE  STOMACH.  495 

gastric  ulceration.  Persons  who  suffer  from  disturbance  of  the  men- 
strual function  are  prone  to  be  hysterical ;  and  it  may  happen  that 
one  of  the  most  marked  traits  of  the  hysterical  disorder  is  that  it 
manifests  itself  by  tenderness  in  the  epigastric  region,  and  by  pain  in 
the  stomach. 

We  thus  may  have  the  most  significant  signs  of  gastric  ulcer,  occur- 
ring, as  so  many  cases  of  amenorrhoea  do,  in  chlorotic  young  women ; 
therefore  happening  in  the  class  among  whom  ulceration  of  the  stomach 
is  most  frequent.  Nay,  the  very  history  may  point  to  the  probability 
of  gastric  ulcer.^  Yet,  generally,  by  close  attention  to  all  the  phe- 
nomena of  the  case,  we  can  arrive  at  a  correct  conclusion.  The  ten- 
derness, as  in  all  local  hysterical  affections,  is  great  on  the  slightest 
touch ;  and  there  is  no  severe  pain  posteriorly  corresponding  to  the 
spot  of  soreness  in  the  epigastric  region.  Pressure  upon  a  spinous 
process  may  cause  pain,  but  it  is  not  the  peculiar  dorsal  pain  of  gastric 
ulceration.  Then,  in  the  hysterical  complaint  there  is  often  hyperses- 
thesia  of  the  skin  in  various  portions  of  the  body,  and  the  apparent 
gastric  distress  bears  no  relation  to  the  taking  of  food,  or  to  the  circum- 
stance of  its  being  of  an  irritating  character  or  otherwise.  The  epi- 
gastric surface  temperature  is  elevated  in  gastric  ulcer,  and  may  even 
exceed  the  temperature  in  the  axilla.^ 

But  to  return  to  the  vomiting  of  blood.  When  this  is  not  trace- 
able to  a  suppression  of  a  natural  discharge,  and  when  it  does  not 
befall  a  person  who  suffers  from  disease  of  the  heart,  or  liver,  or 
spleen,  or  oesophagus,  it  acquires  great  significance.  It  is  the  only 
kind  of  vomit  at  all  distinctive  of  a  gastric  ulcer ;  for  the  substances 
ejected  present  otherwise  appearances  not  different  from  what  they  do 
in  chronic  gastritis.  The  blood  may  be  pure  and  red,  but  it  is  more 
frequently  blackened  by  the  gastric  juice ;  and'  large  quantities  are 
sometimes  passed  by  stool.  Now,  hemorrhage  does  not  take  place  in 
chronic  inflammation  of  the  mucous  membrane  of  the  stomach,  except 
perhaps  in  drunkards,  or  where  there  is  coexisting  disease  of  the  liver 
or  spleen.  In  those  instances  in  which  erosions  exist  on  the  surface, 
the  vomited  mucus  may  be  a  little  streaked  with  blood ;  yet  anything 
hke  a  profuse  hemorrhage  never  happens.  Hence  its  occurrence  in  a 
case  with  the  symptoms  of  chronic  gastritis,  cancer  being  excluded, 
renders  the  presence  of  an  ulcer  probable.  Yet  there  is  a  source  of 
fallacy,  as  I  know  by  having  met  with  such  an  instance,  due  to  removal 
of  the  ovaries  in  an  hysterical  woman  with  marked  gastric  symptoms, 

^  Case  under  my  care,  Philadelphia  Hospital  ;  Medical  and  Surgical  Reporter, 
Feb.  1863. 

^  Hayem,  Revue  des  Sciences  Medicates,  Oct.  15,  1888. 


496  MEDICAL  DIAGNOSIS. 

in  whose  case  subsequent  hsematemesis  repeatedly  occurred.  It  must 
also  be  borne  in  mind  that  we  may  have  gastric  ulceration  mthout 
haematemesis,  and  that  in  pure  hysteria  blood  may  be  vomited. 

The  vomiting  of  the  matters  taken  into  the  stomach  may  be  imme- 
diate, or  not  for  some  time  after  the  food  has  been  swallowed.  Usually 
it  happens  speedily,  and  in  some  mstances  so  speedily  that  there  seems 
to  be  rather  regurgitation  than  vomiting.  But  this  is  rare,  and  in  the 
rarity  is  a  safeguard  against  confounding  gastric  ulcer  with  the  vomit- 
ing of  cerebral  disease,  especially  tumor,  which  I  have  known"  to 
happen  in  a  young  woman  in  whom,  moreover,  vomiting  of  blood  had 
occurred.  In  the  regurgitation,  then,  in  the  frequently  absent  nausea, 
in  the  clean  tongue, — though  coating  may  also  be  absent  in  ulcer, — 
in  the  want  of  oppression  and  weight  at  the  epigastrium,  and  in  the 
headache,  altered  vision,  and  other  nervous  phenomena,  we  have  the 
distinguishing  traits  between  gastric  and  cerebral  vomiting  on  which  to 
lay  stress  in  the  diagnosis  between  disease  of  the  brain  and  gastric 
ulcer,  or  indeed  any  other  serious  stomach  affection.  The  attacks  of 
gastric  pain  that  occur  in  the  gastric  crises  of  locomotor  ataxia  may  be 
misleading.  But  the  absence  of  knee-jerks  and  the  eye-phenomena 
explain  their  meaning.  Constipation  is  present  m  the  large  majority  of 
cases  of  gastric  ulcer.  Pallor  also  is  a  common  manifestation.  The 
number  of  red  blood-corpuscles  usually  undergoes  moderate  diminu- 
tion, while  the  percentag'e  of  hsemogiobin  suffers  a  somewhat  greater 
reduction. 

Perforating  gastric  ulcer  may  lead  to  localized  abscess  in  different 
situations  near  the  stomach,  and  this  abscess  may  burst  into  the  peri- 
toneum, or  be  discharged  externally,  recovery  ensuing.  In  some  in- 
stances the  abscess  forms  beneath  the  diaphragm,  and  may  be  mis- 
taken for  pneumothorax.  Indeed,  this  pyopneumothorax  subphrenicus 
may  show  physical  signs  like  those  of  pneumothorax.  But  it  does  not 
extend  to  the  summit  of  the  chest,  and  there  is  but  little  displacement 
of  the  heart.  Moreover,  the  history  points  to  long-existing  gastric 
derangement.  Pain  in  the  front  of  the  chest  or  in  the  abdomen,  as 
the  cases  of  Penrose  and  Dickinson  ^  prove,  is  an  early  symptom,  and 
is  soon  followed  by  the  physical  signs  of  pneumothorax  or  of  pneu- 
monia. 

In  concluding  this  sketch  of  gastric  ulceration,  two  questions  arise 
which  require  solution :  Does  an  ulcer  always  produce  the  peculiar 
train  of  symptoms  mentioned?  May  not  the  same  phenomena  be 
met  with  in  other  disorders  ?     The  first  question  must  be  answered  in 

^  Clinical  Society's  Transactions,  vol.  xxvi.,  1893. 


DISEASES  OF  THE  STOMACH.  497 

the  negative.  Ulceration  of  the  stomach  may  occasion  nothing  but 
the  symptoms  of  chronic  gastritis  ;  and  even  these  may  not  be  marked. 
The  second  cpestion  is  to  be  answered  in  the  affirmative.  There  is  a 
disorder  with  symptoms  almost  identical  with  those  of  gastric  ulcer, 
the  corrosive  ulcer  of  the^duodenum.  Now,  this  affection,  were  it  more 
frequent,  would  be  a  constant  source  of  error.  It  may  run  an  acute, 
or  at  least  an  apparently  acute,  or  a  chronic  course.  In  either  case  it 
is  scarcely  distinguishable  from  gastric  ulceration.  Trier,  from  an 
analysis  of  twenty-six  cases,  mentions,  among  the  most  important 
grounds  for  a  differential  diagnosis,  a  sensitive  tumor  in  the  epigas- 
trium, proceeding  from  adhesion  with  the  pancreas,  and  jaundice  or 
other  hepatic  phenomena.  But  these  symptoms  are  far  from  constant ; 
and  in  acute  cases,  and  in  those  chronic  cases  which  run  a  latent  course, 
the  diagnosis  is  impossible.  It  may  be  added  that  the  perforating  ulcer 
of  the  duodenum  is  much  more  apt  than  ulcer  of  the  stomach  to  remain 
latent  and  to  lead  rapidly  to  a  fatal  termination.  The  most  certain 
signs  of  duodenal  ulcer  are  the  sudden  and  apparently  causeless  occur- 
rence of  intestinal  hemorrhage,  which  may  recur  and  be  associated 
with  haematemesis  ;  violent  attacks  of  pain  referred  to  the  right  hypo- 
chondrium  or  the  epigastrium  ;  pain  in  the  right  hypochondriac  region 
happening  two  or  three  hours  after  meals  ;  dyspeptic  symptoms,  gen- 
erally of  moderate  degree,  and  diarrhoea.  Duodenal  ulcer  is  thought 
by  some  to  be  almost  invariably  due  to  the  action  of  a  highly  acid 
gastric  juice,  and  to  furnish  the  best  illustration  of  the  so-called  "  peptic 
ulcer."  It  sometimes  follows  burns  of  the  cutaneous  surface.  It  is 
most  common  between  thirty  and  forty  years  of  age,  and,  as  Krauss 
proves,  is  ten  times  more  common  in  men  than  in  women. 

Where  perforation  occurs  from  duodenal  ulcer  the  symptoms  are 
the  same  as  in  perforation  from  gastric  ulcer :  sudden,  agonizing  pain, 
epigastric  first,  then  becoming  diffused  ;  symptoms  of  collapse,  sub- 
normal temperature,  rapid  breathing,  and  vomiting,  which  soon  ceases 
in  the  case  of  perforating  gastric  ulcer,  but  continues  in  duodenal 
ulcer. 

There  is  yet  another  affection  with  symptoms  like  those  of  ulcer, 
an  affection  still  more  serious  and  destructive, — cancer. 

Gastric  Cancer. — Cancer  is  found  more  frequently  in  the  stomach 
than  in  any  other  organ  except  the  uterus.  Of  nine  thousand  one 
hundred  and  eighteen  cases  of  cancer  which  occurred  in  Paris  from 
1837  to  1840,  two  thousand  three  hundred  and  three  were  in  the 
stomach.^     Among  thirty  thousand  cases  analyzed  by  Welch  the  stom- 

^  Walshe  on  Cancer. 


498  MEDICAL  DIAGNOSIS. 

acli  was  involved  in  21.4  per  cent.  The  disease  is  generally  primary. 
It  is  most  often  seated  at  the  pylorus  ;  next  in  frequency  stands  the 
lesser  curvature  ;  then  the  cardiac  orifice  and  the  posterior  wall ;  most 
rarely  does  it  involve  the  whole  viscus.  We  find  all  the  varieties  of 
cancer  affecting  the  stomach :  medullary,  adenomatous,  scirrhous, 
colloid,  squamous.  There  may  be  nodular  tumors  of  varying  consist- 
ency or  more  or  less  diffuse  infiltration  of  the  coats  of  the  stomach. 
Breaking  down  of  the  growth  may  result  in  the  formation  of  ulcers ; 
and  perforation  may  take  place.  Occasionally  carcinoma  develops  in 
the  site  of  a  previous  ulcer.  As  found  by  an  analysis  of  two  thousand 
and  thirty-eight  cases  of  gastric  cancer,  three-fourths  occur  between 
forty  and  seventy  years  of  age.^  Males  suffer  more  commonly  than 
females,  and  whites  far  more  than  blacks. 

The  symptoms  of  cancer  of  the  stomach  are  the  same  as  those  of 
chronic  gastritis, — pain,  tenderness  in  the  epigastrium,  disordered  di- 
gestion, vomiting.  In  a  more  advanced  state  of  the  cancerous  malady 
there  may  be  those  of  gastric  ulcer,  hemorrhage  being  added  to  the  list 
above  given.  There  is  only  one  symptom  distinctive  of  cancer, — 
namely,  the  existence  of  a  tumor. 

But  let  us  see  if  there  be  anything  in  the  pain  and  vomiting,  or  in 
the  circumstances  of  the  case,  by  which,  even  when  a  tumor  cannot 
be  discovered,  the  presence  of  a  cancer  may  be  suspected.  Pain  is  a 
very  constant  symptom  ;  quite  as  constant  as  in  gastric  ulcer.  But  the 
pain  is,  as  a  rule,  more  continuous,  much  less  influenced  by  the  taking 
of  food,  and  more  radiating,  being  often  referred  to  the  right  or  the 
left  hypochondrium.  Its  character  is  very  varying.  It  may  be  dull, 
or  gnawing,  or  it  may  be  lancinating.  It  may  be  slight,  or  it  may 
amount  to  excruciating  agony.  But  it  is  a  mistake  to  suppose  that  a 
cancer  of  the  stomach  necessarily  causes  severe  or  lancinating  pain. 
Again,  it  should  be  borne  in  mind  that  the  part  diseased  may  ulcerate, 
and  then  the  pain  is  exactly  like  that  of  an  ordinary  gastric  ulcer,  and 
is  affected  in  the  same  way  by  food.  The  most  marked  seat  of  the 
pain  is  sometimes  under  the  shoulder-blade. 

Vomiting  is  not  an  invariable  result  of  cancer ;  yet  it  is  a  frequent 
one.  The  seat  of  the  morbid  growth  determines,  to  a  great  extent, 
the  occurrence  of  vomiting  and  the  period  at  which  it  will  happen. 
When  the  body  of  the  stomach  is  attacked,  and  the  orifices  are  not 
obstructed,  it  may  not  take  place  at  all ;  or,  if  it  take  place,  it  is  within 
a  brief  time  after  meals.  When  the  disease  has  narrowed  the  car- 
diac extremity,  vomiting   supervenes  almost  immediately ;   the  food 

^  Welch,  Pepper's  System  of  Practical  Medicine. 


DISEASES  OF  THE  STOMACH.  499 

has  hardly  been  swallowed  before  it  is  brought  up  again.  But  when, 
as  is  much  more  common,  the  pylorus  is  constricted,  the  food  is  not 
thrown  off  until  it  attempts  to  pass  through  into  the  intestine ;  there- 
fore not  until  a  considerable  time  after  meals. 

With  respect  to  the  character  of  the  substances  ejected,  this  too 
depends  on  the  seat  of  the  cancer,  and  the  time  at  which  the  vomiting 
occurs.  If  it  ensue  several  hours  after  meals,  the  cast-off  matter  con- 
sists of  food  partly  digested,  partly  in  a  state  of  highly  acetous  fer- 
mentation. An  enormous  c{uantity  of  acid  material,  the  accumulation 
of  several  meals,  is  sometimes  brought  up  during  one  act  of  emesis. 
The  ejected  matter  may  be  intermingled  with  blood,  and  have  a  black- 
ish or  reddish-brown,  "  coffee-ground"  appearance ;  or  the  mucus 
which  is  thrown  up  may  be  tinged  with  black  flakes  :  in  either  case  we 
find  reduced  hsematin.  Rarely  is  any  considerable  amount  of  un- 
mixed blood  vomited. 

Free  hydrochloric  acid  is  often  absent  from  the  vomited  contents 
of  the  stomach  or  from  the  "  trial  meal,"  especially  in  cancer  of  the 
pylorus.  But  we  must  not  forget  that  it  is  also  absent  in  amyloid 
degeneration,  in  simple  gastric  achylia  and  in  atrophy  of  the  gastric 
tubules,  in  many  fevers,  and  occasionally  in  chronic  gastritis.  The 
persistent  presence  of  free  hydrochloric  acid  renders  the  existence  of 
carcinoma  very  improbable. 

It  is  at  times  a  very  difficult  diagnosis  between  cancer  of  the 
stomach  in  which  no  tumor  can  be  found  and  achylia  gastrica.  This 
absence  of  secretion  of  the  gastric  juice  shows  persistent  loss  of  hydro- 
chloric acid  and  of  ferments,  and  is  found  as  a  primary  secretory 
debility,  especially  in  neurasthenics.  But  a  graver  form  is  associated 
with  atrophy  of  the  gastric  tubules,  and  it  is  in  this  affection  that, 
irrespective  of  the  chemical  signs,  the  marked  dyspeptic  symptoms, 
the  progressive  debility  and  aneemia,  and  the  severe  gastralgia  make 
us  think  of  cancer.  Vomiting,  however,  is  not  a  prominent  symptom, 
and,  unhke  cancer,  diarrhoea  is. 

In  many  cases  of  carcinoma  of  the  stomach,  lactic  acid  is  to  be 
found  in  the  gastric  contents  after  the  administration  of  a  special  trial 
meal,  free  from  lactic  acid  and  lactates,  and  consisting  of  oatmeal  gruel 
(a  tablespoonful  of  oatmeal  to  a  c{uart  of  water)  with  a  little  salt.^  This 
phenomenon  is  rare  under  other  conditions,  and  though  not  pathog- 
nomonic of  gastric  cancer,  when  existing  with  dyspeptic  symptoms 
and  absence  of  hydrochloric  acid,  it  is  almost  conclusive.  Microscopic 
examination  may  disclose  the   presence  in  the   cancerous   particles 

^  Boas,  Miinchener  Medicinische  Wochenschrift,  1893,  No.  43,  p.  805. 


500  MEDICAL  DIAGNOSIS. 

found  in  the  gastric  contents  or  the  washwater  of  large  numbers  of 
cells  showing  mitosis,  and  of  characteristic  "  concentrically  arranged 
conglomerations  of  cells  ;"  ^  also  of  unusually  long,  non-motile  bacilU.^ 
These  bacilli  have  the  power  of  forming  lactic  acid  freely.  They  are 
not  pathognomonic  of  cancer,  since  they  have  been  met  with  also  in 
simple  hypertrophic  stenosis  of  the  pylorus,  but  they  are  very  im- 
portant and  significant.  The  Oppler  bacillus  existed  in  nineteen  out 
of  twenty  cases  of  gastric  cancer  examined  by  Kaufmann.  In  gastric 
carcinoma,  further,  the  motility  of  the  stomach  is  generally  much 
impaired,  the  ferments  are  defective  or  absent, 

A  close  study  of  the  pain  and  vomiting  may  furnish  evidence  by 
which  the  existence  of  a  gastric  cancer  may  be  strongly  suspected. 
There  are  a  few  other  circumstances  which  would  strengthen  this 
suspicion :  such  as  the  sour  eructations,  the  extreme  flatulency,  the 
persistent  fetid  breath,  obstinate  constipation,  anorexia  with  progressive 
loss  of  flesh,  and  the  cachetic  appearance  of  the  patient,  who  is  pale 
and  tired-looking,  or  whose  face  is  of  a  color  which  seems  to  have 
arisen  from  a  combination  of  the  hue  of  chlorosis  and  that  of  jaundice. 
The  supposed  characteristic  straw  color  of  cancer  is  not  often  met 
with.  The  temperature  is  generally  below  the  norm ;  but  there  are 
exceptional  cases  in  which  a  moderate  amount  of  irritative  fever 
accompanies  the  gradual  wasting.  Oildema  of  the  ankles  is  a  frequent 
symptom  of  the  advancing  disease.  In  some  instances  coma  happens 
similar  to  diabetic  coma,  or  tetany,  as  Kussmaul  pointed  out.  There 
is  a  form  in  which  rapid  enlargement  of  the  liver,  some  fever,  and 
erythematous  eruptions  occur.^  The  blood  presents  scarcely  distinc- 
tive changes.  The  number  of  red  corpuscles  is  usually  diminished, 
and  the  percentage  of  haemoglobin  in  yet  greater  degree.  The  number 
of  white  corpuscles  may  be  somewhat  increased,  with  an  absence  of 
digestion-leucocytosis.  Acetone  and  peptone  have  been  found  in  the 
urine. 

Now,  should  all  these  symptoms  be  met  with  in  a  person  who  is 
steadily  becoming  feebler,  whose  age  is  above  forty,  in  whose  family 
cancer  is  hereditary ;  should  cancerous  tumors  develop  themselves  in 
any  other  part  of  the  body, — the  suspicion  entertained  would  be  con- 
verted into  a  certainty.  But  it  is  not  often  that  a  case  presenting 
a  combination  of  all  the  symptoms  enumerated  is  met  with.  I 
repeat,  the  most  distinctive  sign  is  a  tumor :  when  this  is  not  detected, 
uncertainty  hangs  over  any  diagnosis  of  gastric  cancer. 

^  Ewald,  Klinik  der  Verdauungskrankheiten,  3.  Aufl.,  2.  Band,  p.  342. 
2  Oppler,  Deutsche  Medicinische  Wochenschrift,  1895,  No.  5. 
^  Hanot,  Archives  Generales  de  Medecine,  Sept.  1892. 


DISEASES  OF  THE  STOMACH. 


501 


To  contrast,  then,  cancer  of  the  stomach  with  chronic  gastritis  and 
gastric  ulcer : 


Chronic  Gastritis. 
Pain  at  the  epigastrium  some- 
wliat  augmented  by  food ;  also 
soreness.    Both  constant,  al- 
though comparatively  slight. 


Tongue  usually  hea^iily  coated ; 
may  be  clean. 


Acid  eructations. 
SjTiiptoms        of 
marked. 


indigestion 


Sometimes  vomiting ;  especially 
morning  vomiting  in  alcoholic 
cases. 

No  hemorrhage,  or  but  trifling 
hemorrhage  ;  at  most,  blood- 
streaks  in  vomited  matter. 

Bowels  constipated. 

No  fever. 


Not  much  emaciation ;  no  ca- 
chectic appearance. 


Not  confined  to  any  age.  More 
common  in  middle-aged  or 
elderly  people.  Common  in 
alcoholics. 

Disease  may  be  relieved  or 
cured ;  is  often  of  very  long 
duration. 

No  tumor. 

Contents    of    stomach   contain 

generally    free    hydrochloric 

acid. 
No  dropsy. 


Gasteio  Ulcee. 

Pain  at  the  epigastrium  much 
augmented  by  food ;  subsides 
when  this  is  digested ;  parox- 
ysms of  pain,  a  strictly  local- 
ized soreness  to  the  touch  in 
the  epigastric  region,  some- 
times a  painful  spot  over  the 
lower  dorsal  vertebrae.  Inter- 
missions in  the  pain  of  consid- 
erable length  are  frequent. 

Tongue  dry,  red,  streaked  in 
middle ;  or  smooth  and  moist 
or  slightly  coated. 

Eructations  occur,  are  not  acid. 

Symptoms  of  indigestion  some- 
times very  slight. 

Vomiting  usually  immediately 
or  soon  after  taking  food; 
often  an  early  symptom. 

Abundant  hemorrhage  from  the 
stomach  common. 

Bowels  may  or  may  not  be  con- 
stipated ;  usually  are. 
No  fever. 


Frequently  extreme  pallor  and 
debility. 


May  occur  in  middle-aged  per- 
sons ;  but  is  most  frequently 
seen  in  young  adults,  espe- 
cially in  young  women. 

Duration  uncei'tain ;  may  get 
well,  may  run  on  rapidly  to 
perforation ;  on  the  other 
hand,  may  last  for  years. 

No  tumor. 

Hydrochloric  acid  in  excess  in 
contents  of  stomach. 


No  dropsy. 


Gastric  Cancer. 
Pain  frequently  of  a  radiating 
kind,  often  paroxysmal,  not 
unusually  severe  and  lanci- 
nating, but  not  of  necessity  as- 
sociated with  soreness ;  little 
or  not  at  all  affected  by  food. 
Pain  rarely  remits ;  never  in- 
termits for  any  considerable 
time. 

Tongue  pale  and  thickly  coated. 


Fetid  eructations. 

Symptoms  of  indigestion 
marked.  Anorexia ;  ex- 
tremely sour  stomach. 

Vomiting  a  very  frequent  symp- 
tom ;  occurs  sometimes  on  an 
empty  stomach ;  usually  pre- 
ceded by  other  symptoms. 

Hemorrhage  not  very  abundant, 
but  occasioning  frequently 
coffee-ground  looking  vomit. 

Bowels  obstinately  constipated. 

Intercurrent  attacks  of  slight 
fever  may  occur;  but  tem- 
perature often  subnormal. 

Progressive  loss  of  flesh,  and 
cachexia  ;  at  times  hypertro- 
phy of  the  peripheral  lym- 
phatic glands,  especially 
above  the  clavicles. 

Most  common  in  elderly  people ; 
rarely  occurs  in  persons  under 
forty  years  of  age. 

Average  duration  one  year ;  may 
be  shorter;  is  seldom  longer; 
very  rarely  reaches  two  years. 

Generally  a  tumor. 

As  a  rule,  no  hydrochloric  acid 

in  contents  of  stomach  ;  often 

lactic  acid  present. 
CEdema    of    ankles   often   met 

with. 


The  differences  laid  down  in  the  table  are  derived  from  an  analysis 
of  well-marked  cases.  In  the  early  stages  of  the  cancerous  malady, 
a  differential  diagnosis  is  impossible.  Subsequently,  as  already  stated, 
the  detection  of  a  tumor  plays  an  important  part  in  any  deduction. 
But  this  remark  does  not  apply  to  cases  of  cancer  of  the  cardiac 
orifice,  which  are  rare,  and  in  which  a  tumor,  from  its  deep  situation, 
almost  always  eludes  discovery.     Such  cases  are,  however,  discriini- 


502  MEDICAL   DIAGNOSIS. 

nated  by  their  presenting  the  same  signs  as  a  stricture  of  the  oesoph- 
agus low  down ;  indeed,  they  are  very  constantly  combined  with  a 
narrowing  of  the  tube,  produced  by  the  cancer  spreading  to  it.  Cancer 
at  other  parts  of  the  organ  occasions  a  perceptible  tumor  in  about 
three-fourths  of  all  the  instances  :  its  situation  is,  of  course,  not  always 
the  same.  Where  no  tumor  can  be  discerned,  and  particularly  if,  as 
may  happen,  portions  of  the  stomach  remain  healthy  and  the  diges- 
tive disturbances  are  slight,  the  existence  of  cancer  may  not  reveal 
itself  by  any  symptoms,  and  the  case  run  a  latent  course.^  In  most 
cases  without  tumor  we  shall  be  rarely  wrong  in  making  the  diag- 
nosis of  gastric  cancer,  if  there  be  persistent  stomach  symptoms  in  a 
person  of  middle  or  of  above  middle  age,  whose  digestion  has  been 
previously  excellent,  who  has  epigastric  pain,  is  losing  flesh  and 
strength,  is  not  improved  by  treatment,  and  shows  an  absence  of 
hydrochloric  acid  in  the  trial  meal. 

A  cancer  of  the  anterior  wall  produces,  as  a  rule,  fulness,  resist- 
ance, and  percussion  dulness  in  the  epigastric  region.  A  cancer  in- 
volving the  greater  curvature  gives  rise  to  a  swelling  near  the  umbili- 
cus, or  to  one  extending  towards  either  hypochondrium.  The  tumor 
formed  by  cancer  of  the  pylorus  is  commonly  felt  plainly  a  little  to 
the  right  of  the  median  line,  and  one  to  two  inches  below  the  carti- 
lages of  the  ribs.  In  women  its  position  is  apt  to  be  even  lower  than 
this  ;  and,  indeed,  in  both  sexes  the  situation  of  the  indurated  pylorus 
is  very  variable.  It  may  be  pushed  down  to  near  the  umbilicus  ;  nay, 
it  has  been  discerned  near  the  anterior  superior  spinous  process  of  the 
ilium.^  It  is  rarely  found  in  the  left  hypochondrium,  but  not  infre- 
quently in  the  right.  Then  it  may  form  adhesions  to  the  liver,  which 
viscus  at  times  so  completely  covers  the  tumor  as  to  render  this  impos- 
sible of  detection. 

The  reason  why  the  swelling,  in  not  a  few  instances,  shows  itself 
much  lower  than  the  normal  seat  of  the  pylorus  is  obvious.  During 
meal  after  meal  the  organ  seeks  to  overcome  the  resistance  offered  by 
the  narrowed  pyloric  orifice,  and  does  so  with  great  and  increasing 
difficulty.  The  constantly  repeated  and  long-continued  struggle  leads 
to  hypertrophy  of  the  muscular  coat  and  to  distention  of  the  hollow 
viscus. 

The  tumor  may  or  may  not  be  movable, — generally  is  not ;  its 
surface  may  be  either  smooth  or  nodulated.  It  may  be  large  and  dis- 
tinct, or  small  and  requiring  a  careful  examination  to  distinguish  it 

^  See  report  of  case  under  my  care  at  the  Pennsylvania  Hospital,  published  in 
Anier.  Journ.  Med.  Sci.,  vol.  lii.,  1866. 

^  See  Lebert's  cases  in  Traite  pratique  des  Maladies  cancereuses. 


DISEASES  OF  THE  STOMACH.  503 

from  the  surrounding  and  more  yielding  textures.  Percussing  over  it 
elicits  a  dull  sound,  usually  mixed  with  a  tympanitic  note.  The  tumor 
is  much  more  perceptil3le  on  some  days  than  it  is  on  others. 

But  is  a  swelling  in  the  region  of  the  stomach  strictly  pathogno- 
monic of  gastric  cancer  ?  No  ;  not  even  when  the  swelling  has  been 
ascertained  to  belong  to  that  viscus.  At  times  the  cicatrix  marking  a 
previous  ulcer,  or  even  the  indurated  and  thickened  margins  of  an 
existing  ulcer,  may  be  palpable  through  the  abdominal  walls  and  raise 
the  cfuestion  of  a  new  growth.  A  mere  fibroid  thickening  of  the 
pylorus  will  occasion  a  tumor,  and,  moreover,  produce  symptoms 
which  resemble  so  closely  those  of  malignant  disease  at  the  orifice 
that  I  much  doubt  the  possibility  of  distinguishing  during  life,  with 
any  certainty,  between  the  two  affections.  Let  us  take  this  case, 
which  I  saw  with  Dr.  Moss,^  as  an  example. 

A  woman,  aged  forty,  complained  of  pain  at  the  pit  of  the  stomach, 
and  of  a  heavy  sensation  throughout  the  abdomen.  For  some  months 
she  had  been  suffering  from  indigestion,  and  had  been  losing  flesh. 
She  had  a  slight  cough,  with  impaired  resonance  at  the  apices.  The 
bowels  were  obstinately  constipated,  the  tongue  was  smooth  and  red, 
the  pulse  feeble.  She  vomited  shortly  after  meals,  yet  never  any- 
thing but  the  ingesta.  There  was  no  pain  on  pressure  over  the  pylo- 
rus ;  but  a  greater  resistance  to  the  finger  than  usual  was  detected. 
The  further  progress  of  the  complaint  was  marked  by  incessant  vom- 
iting, only,  however,  after  meals.  Once,  and  once  only,  did  it  cease 
for  several  days ;  and  then  without  apparent  cause.  As  the  case  drew 
towards  its  fatal  termination,  the  patient  was  much  troubled  with  acid 
eructations,  and  had  occasionally  slight  febrile  attacks.  The  distress 
in  the  epigastrium  increased.  About  three  weeks  before  her  death  she 
was  seized  with  lancinating  jDains  under  both  patellae ;  they  were  ac- 
companied by  pricking  sensations  and  numbness  in  the  legs,  and  an 
inability  to  walk.  The  pains  gradually  ceased,  but  the  numbness  and 
loss  of  motion  increased.  She  died,  utterly  exhausted  by  the  ab- 
dominal pains  and  the  incessant  vomiting,  about  three  months  after 
she  began  to  reject  her  food.  On  post-mortem  examination,  tuber- 
cular deposits  were  found  at  the  apices  of  the  lungs.  The  abdominal 
viscera  were  healthy,  except  the  stomach  ;  and  this,  too,  was  healthy, 
save  at  its  pyloric  orifice,  which  was  so  narrowed  that  the  tip  of  the 
little  finger  could  hardly  be  forced  into  it.  The  mucous  lining  lay  in 
folds,  but  on  dissection  was  found  to  be  perfectly  normal.  At  the 
pylorus,  but  only  there,  the  submucous  and  the  muscular  coat  were  uni- 

^  Published  in  full  in  the  Proceedings  of  the  Pathological  Society  of  Philadel- 
phia, vol.  i. 


504  MEDICAL  DIAGNOSIS. 

formly  thickened.  Examined  microscopically,  they  contained  nothing 
but  fibroid  tissue,  spindle-shaped  fibre-cells,  and  very  distinct  organic 
muscular  fibres. 

Now,  here  is  a  case  which  was  not  cancer ;  yet  it  had  the  symp- 
toms of  cancer.  It  is  true  that  the  absence  of  blood  and  of  glairy 
mucous  in  the  matter  vomited,  and  the  indistinctness  of  the  swelling, 
in  spite  of  the  great  emaciation,  were  against  the  supposition  of  cancer 
of  the  pylorus.  Still,  no  inference  based  on  these  data  alone  could  be 
strictly  trusted.  The  disease  was  combined  with  tubercular  deposits 
in  the  lung.  Nor  is  this  the  only  example  of  the  combination  which 
has  come  under  my  notice.  And  when  a  tubercular  state  of  the  lung 
has  been  fairly  made  out,  and  there  exist  at  the  same  time  signs  of 
pyloric  obstruction,  I  should  make  a  diagnosis  that  this  is  not  of  a  can- 
cerous nature,  but  consists  simply  of  an  increased  development  of  the 
submucous  coat,  with  probably  subsequent  hypertrophy  of  the  muscu- 
lar tunic. 

The  fibroid  thickening  may  extend  throughout  the  whole  stomach, 
and  there  may  be  also  hyperplasia  of  the  muscular  coat.  Such  cases 
differ  from  cancer  by  their  long  duration  ;  the  absence  of  hemorrhage, 
of  the  peculiar  vomit  of  cancer,  and  of  severe  pain ;  and  by  the  more 
uniform  gastric  swelling.  The  affection  is  sometimes  observed  in 
spirit-drinkers ;  it  may  be  met  with  in  children.  Its  discrimination 
from  cancer  is  never  a  certainty.  In  a  case  reported  by  Cornell,^ 
which  was  complicated  with  tuberculous  peritonitis,  loss  of  digestive 
power  was  indicated  by  unbroken  starch  grains  in  the  vomit.  The 
absorptive  activity  of  the  stomach  tested  by  iodine  was  normal.  Boas  ^ 
states  that  in  these  non-malignant  cases  with  pyloric  stenosis,  though 
there  are  fermentative  processes,  lactic  acid  is  absent. 

There  are  other  diseases  than  those  of  the  stomach  which  may 
occasion  a  tumor  in  its  region  and  are  thus  liable  to  be  mistaken  for 
gastric  cancer.  Prominent  among  these  are  enlargement  of  the  liver 
projecting  into  the  epigastrium,  tumors  of  the  omentum,  and  diseases 
of  the  pancreas  and  of  the  kidney.  Of  course,  the  stomach  symptoms 
proper  are  not  so  marked  in  these  affections,  and  in  some  they  may 
be  wholly  wanting ;  examination  of  the  gastric  contents  and  of  the 
urine,  and  due  regard  to  the  history  of  the  case,  will  show  us  the 
truth  about  many  ;  and,  after  all,  the  best  way  of  preventing  ourselves 
from  falling  into  error  is  to  seek  in  any  case  of  supposed  gastric 
cancer  for  these  other  diseases,  and  to  see  if  their  chief  symptoms  are 
present. 

^  Montreal  Medical  Journal,  Aug.  1892. 

^  Miincliener  Medicinische  Wochenschrift,  Oct.  1893. 


DISEASES  OF  THE  STOMACH.  505 

Resting  with  this  general  statement,  I  shall  not  take  up  the  differ- 
ential diagnosis  of  all  the  many  affections  mentioned ;  especially  as 
some  are  referred  to  when  treating  of  partial  abdominal  enlargements 
and  of  cancer  of  the  liver.  But  there  are  two  which  may  be  here 
specially  looked  at :  one  is  omental  cancer,  the  other  kidney  affection 
attended  with  marked  swelling,  such  as  occurs  in  hydronephrosis, 
pyonephrosis,  abscess,  hydatids,  and  morbid  growths. 

In  omental  cancer  there  is  far  less  dyspepsia,  hemorrhage  and 
coffee-ground  vomit  are  absent,  the  tumor  appears  to  occupy  chiefly 
the  site  of  the  greater  curvature,  the  swelling  is,  or  soon  becomes, 
more  generally  diffuse,  and  hydrochloric  acid  and  the  digestive  fer- 
ments are  present  in  the  gastric  contents. 

In  the  kidney  affections  referred  to,  the  history  is  of  great  impor- 
tance, and  we  include  in  this  history  the  passage  of  renal  calculi  as 
bearing  on  some  forms  of  kidney  enlargement,  especially  abscess  from 
impaction  of  stones  ;  the  limits  of  the  mass,  though  this  may  project 
into  the  epigastrium,  will  scarcely  be  those  of  a  gastric  cancer.  But 
the  most  certain  safeguard  against  error  is  careful  and  repeated  exam- 
ination of  the  urine  and  of  the  gastric  contents. 

As  regards  the  urine,  the  observations  of  Rommelaere  ^  seem  to 
show  that  its  analysis  may  be  of  value  in  the  diagnosis  of  the  different 
forms  of  gastric  disease.  Thus,  a  cancerous  ulceration  of  the  stomach 
is  attended  with  decrease  of  urea,  and  the  chlorides  are  diminished. 
In  simple  gastric  ulcer  these  are  in  normal  quantity  or  in  excess ;  so 
is  the  urea.  In  spreading  gastric  ulcer  the  chlorides  are  decreased, 
but  there  is  a  normal  or  increased  amount  of  urea  and  urates. 

In  a  certain  number  of  cases,  variously  estimated  between  two  and 
nine  per  cent.,  ulcer  of  the  stomach  exists  first,  and  then  cancer  super- 
venes. This  may  take  the  form  of  a  tumor,  or  the  cancerous  disease 
invade  the  ulcer,  and  no  tumor  occur.  Such  cases  are  mostly  chronic, 
and  present  the  history  of  preceding  ulcer.  The  gastric  juice  generally 
retains  its  hyperacidity.  There  are  often  signs  of  a  gastric  neurosis ; 
then  loss  of  weight  and  cachexia  are  noticed,  and  want  of  response  to 
treatment;  all  unlike  pure  gastric  ulceration.  A  further  significant 
sign  is  coffee-ground  vomit.  But  the  most  conclusive  would  be  fur- 
nished by  the  microscopic  examination  of  particles  of  the  morbid 
structure  in  washings  of  the  stomach. 

Dilatation  of  the  Stomach. — This  happens  frequently  in  con- 
nection with  obstruction  of  the  pylorus,  whether  cancerous  or  fibroid, 

1  Journal  de  Medecine  de  Bruxelles,  1883  ;  quoted  in  the  Lancet,  Sept.  1  and 
Oct.  27,  1883. 


506  MEDICAL  DIAGNOSIS. 

but  it  is  also  met  with  independently  of  this  structural  lesion.  The 
latter  form  occurs  from  weakening  of  the  muscular  coats  produced  by- 
malnutrition  or  impaired  innervation,  and  has  been  noticed  as  an 
attendant  upon  anaemia  or  hysteria,  or  following  fevers,  or  obstruction 
of  the  upper  part  of  the  bowel,  or  compression  of  the  pylorus  by  an 
enormous  gall-stone,^  or,  as  Bamberger  mentions,  dislocation  of  the 
stomach  by  omental  hernias.  Edinger  has  proved  that  it  may  be  asso- 
ciated with  amyloid  degeneration  of  the  vessels  or  of  the  muscular 
coat  of  the  stomach.  The  chief  signs  of  a  dilated  stomach  in  either . 
form  are  the  rejection  of  food  mostly  in  large  quantities  and  retained 
for  days ;  fermented  and  vomited  matter  containing  often  torulse  and 
sarcinag ;  extension  of  the  tympanitic  note  of  the  gastric  region,  de- 
tected by  percussion,  to  much  below  the  umbilicus  ;  a  splashing  sound 
when  the  patient  moves,  particularly  after  drinking,  and  gurgling  on 
sudden  pressure ;  the  low  line  of  dulness  occasioned  by  fluids  in  the 
distended  organ,  and  the  change  of  the  dulness  with  the  position  of 
the  patient ;  and  slowly  i3rogressing  emaciation.  The  character  of  the 
gastric  secretion  and  that  of  the  contents  of  the  stomach  after  a  trial 
meal  vary  with  the  nature  of  the  causative  condition.  As  a  rule,  there 
are  increased  acidity  from  the  acids  of  decomposition  and  diminished 
absorptive  and  motor  activity.  The  general  nutrition  suffers  as  assim- 
ilation is  more  and  more  interfered  with.  In  doubtful  cases  the  organ 
may  be  examined  and  its  limits  traced  by  distending  it  with  ordinary 
air,  or  with  carbon  dioxide.  Displacement  of  the  right  kidney  has 
been  observed  in  a  number  of  cases. 

The  sounds  of  the  heart  heard  over  the  dilated  stomach  often  have 
a  metallic  ring,  but,  irrespective  of  this,  peculiar  gurgling  sounds,  sys- 
tolic in  rhythm,  and  evoked  by  the  action  of  the  heart,  have  been  met 
with  by  Franck  and  other  observers.  Dilatation  of  the  stomach  may 
occasion  serious  nervous  symptoms.  I  have  known  convulsions  to 
occur,  and  tetany  has  been  noticed.^  The  dilatation  occasionally  hap- 
pens in  an  acute  manner,  and  occurs  in  children  ^  as  well  as  in  adults. 
As  a  rule,  the  muscular  coat  is  not  hypertrophied,  but,  in  the  cases  in 
which  an  obstruction  at  the  pylorus  exists,  this  is  frequent  at  first, 
ultimately  giving  place  to  atrophy. 

To  tell  the  atonic  cases  from  those  due  to  narrowing  at  the  pylorus 
is  generally  not  difficult ;  we  can  detect  a  hard  swelling,  or  find  the 
resistance  with  a  stomach  sound.  In  cancerous  obstruction  the  gastric 
juice,  as  a  rule,  contains   no  hydrocloric  acid,  but  we  obtain  lactic 

^  Minkowski,  quoted  by  Ewald. 

^  Bulletins  et  Memoires  des  Hopitaux  de  Paris,  t.  xx.,  1884. 

^  Archives  Generales  de  Medecine,  Aug.  1884. 


DISEASES  OF  THE  STOMACH.  507 

acid.  In  other  forms  of  stomach  chlatation,  particularly  in  the  atonic 
form/  we  find  hydrochloric  acid,  as  well  as  the  acids  of  decomposi- 
tion and  fermentation,  acetic  acid,  and  butyric  acid. 

The  stomach  may  be  unduly  large  without  giving  rise  to  any 
symptoms.  This  condition  of  megalogastria  is  to  be  distinguished 
from  gastric  dilatation  by  the  absence  of  the  symptoms  of  the  latter, 
as  well  as  of  derangement  of  secretion,  absorption,  and  propulsion. 

Enlargement  of  the  stomach  is  to  be  distinguished  from  displace- 
ment of  the  organ, — gastroptosis  or  GlenarcVs  disease.  The  condition 
is  chiefly  due  to  comjoression  of  the  waist  by  the  corset,  or  to  relaxation 
of  the  ligamentous  attachments  of  the  stomach,  produced  by  general 
debility  and  emaciation,  or  to  weakness  of  the  abdominal  walls,  such 
as  follows  pregnancies.  Gastroptosis  is  often  associated  with  a  similar 
displacement  of  other  abdominal  viscera, — splanchnoptosis  or  enterop- 
tosis.  There  are  present,  in  addition  to  symptoms  of  digestive  derange- 
ment and  the  obvious  evidences  of  the  dislocation  of  the  viscera, 
which  are  best  obtained  by  inflating  the  stomach  with  air  or  with  car- 
bon dioxide,  manifestations  of  functional  nervous  disturbance.  Among 
the  first  are  impaired  or  perverted  appetite,  epigastric  fulness  and  dis- 
tention, eructation,  acid  taste  and  dryness  of  the  mouth,  burning  or 
colicky  pains  at  the  pit  of  the  stomach  some  hours  after  eating,  dimin- 
ished hydrochloric  acid,  pain  in  the  back,  and  constipation  alternating 
with  seeming  diarrhoea.  The  nervous  symptoms  include  a  feeling  of 
weakness,  general  irritability,  mental  depression,  headache  or  a  sense 
of  fulness  in  the  head,  vertigo,  heaviness  of  the  lower  extremities, 
coldness  of  hands  and  feet,  palpitation  of  the  heart,  heavy  sleep,  and 
frequently  sacral  pains.  Emaciation  takes  place,  with  impoverishment 
of  the  blood,  acne,  and  other  changes  in  the  skin,  and  falling  out  of 
the  hair.  In  gastroptosis  the  lesser  curvature  of  the  stomach  becomes 
evident  after  inflation,  the  pylorus  is  lowered,  the  organ  is  in  a  more 
vertical  position. 

A  certain  number  of  cases  are  associated  with  dilatation  of  the 
stomach.  Gastroptosis  is  infinitely  more  common  in  women  than  in 
men, — ninety  per  cent,  as  compared  with  five,  says  Meinert,^ — the 
smallest  estimate  places  it  at  fifty  per  cent. 

Dilatation  of  the  stomach  may  be  confounded  with  dilatation  of 
the  large  intestine.  But  the  gastric' sympl^oms  of  the  former  malady  are 
of  great  significance.  Moreover,  we  may  make  use  of  the  salol  test 
in  the  discrimination.     Salol  is   not  acted  upon  by  the  acid  gastric 

^  Germain  See,  Bulletin  de  TAcademie  de  Medecine,  May,  1888. 
2  Centralhlatt  fiir  innere  Mediciii,  1886,  Nos.  12  and  13. 


508  MEDICAL   DIAGNOSIS. 

juice,  but  is  changed  into  salicylic  acid  by  the  alkaline  intestinal  secre- 
tion. The  salicylic  acid  manifests  itself  in  the  urine  of  healthy  per- 
sons in  from  half  an  hour  to  an  hour,  as  shown  by  the  addition  of  a 
drop  of  tincture  of  chloride  of  iron  into  the  urine  giving  it  a  violet 
color.  In  dilatation  of  the  stomach  salicylic  acid  does  not  appear  for 
two  or  three  hours  after  salol  has  been  taken. 

Hour-Grlass  Stomach.^ — During  digestion  a  constriction  occurs 
near  the  middle  of  the  stomach,  almost  entirely  separating  the  cardiac 
from  the  pyloric  half.  This  state  may  be  a  permanent  one,  and  the 
hour-glass  stomach  produce  decided  symptoms.  The  hour-glass  con- 
striction may  also  be  congenital,  due  to  the  contraction  from  a  cancer 
or  cicatrizing  ulcer,  or  torsion  from  peritoneal  adhesions.  It  is  very 
rare  under  the  age  of  twenty,  and  is  vastly  more  common  in  women 
than  in  men.  The  history  is  frequently  that  of  gastric  ulceration  with 
intense  gastric  pain  and  obstinate  vomiting,  often  of  food  that  has 
been  for  some  time  in  the  stomach ;  the  more  fluid  parts  of  the 
ingesta  are  retained ;  there  are  apparent  dysphagia,  succussion  splash 
in  the  low^er  part  of  the  stomach  remaining  even  after  lavage,  and  a 
peculiar  gurgling  sound,  described  by  Betz  as  bruit  de  glouglou.^  In- 
sufflation of  the  stomach,  the  gastrodiaphane,  and  the  X-rays  have  also 
aided  in  the  diagnosis,  which  is  now  assuming  considerable  interest, 
as  hour-glass  stomachs  have  been  recognized  and  successfully  oper- 
ated on.^ 

SECTION  11. 

DISEASES    OF    THE    INTESTINES    AND    OF    THE    PEmTONEUM. 

In  considering  the  diseases  of  the  intestines,  we  meet  with  symp- 
toms the  import  of  which  we  have  examined  in  connection  mth  affec- 
tions of  the  stomach.  We  encounter  nausea,  vomiting,  and  impaired 
digestion.  These  may  be  sympathetic,  dependent  upon  coexisting 
gastric  disorder,  or  be  the  result  of  intestinal  indigestion.  In  this  the 
signs  of  indigestion  are  chiefly  seen  by  the  non-digestion  and  acid  fer- 
mentation of  starchy  matter,  and  the  incomplete  action  on  fatty  sub- 
stances. Symptoms  which  in  the  study  of  intestinal  affections  we  lay 
much  stress  on  are  pain  and  the  character  of  the  fecal  discharges^ 

1  This  has  been  investigated  in  an  admirable  paper  on  the  shape  and  position 
of  the  stomach,  by  Bettmann,  Philadelphia  Monthly  Medical  Journal,  March,  1899. 

^  Case  of  Jaworski,  Wiener  Medizinische  Presse,  No.  51,  1897. 

*  See  reference  to  cases  in  Bettmann' s  paper  quoted,  and  in  Perret  I'Estomac 
biloculaire,  These  de  Paris,  1896. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       509 

As  regards  the  former,  we  draw  the  truest  inferences  from  its  kind 
rather  than  from  its  mere  occurrence. 

Alvine  Discharges. — The  faeces  consist  of  about  one-fourth 
soHds  and  three-fourths  water.  Dry,  hard  stools  depend  upon  an 
absorption  of  the  fluid  contents,  as  in  constipation. 

Watery  stools  are  observed  Whenever  a  large  quantity  of  the  serum 
of  the  blood  finds  its  way  through  the  intestinal  coats.  They  are  met 
with  after  the  administration  of  saline  purgatives,  in  serous  diarrhoea, 
and  in  cholera.  Their  hue  varies :  they  may  be  almost  colorless,  or 
tinged  with  yellow.  Sometimes,  although  very  thin  and  watery,  they 
are  decidedly  yellow ;  again  they  are  rendered  turbid  by  the  dis- 
semination of  whitish  flocculi,  or  cast-off  epithelium,  or  by  mucus. 
Whether  they  be  yellow  or  colorless  depends  on  the  existence  or  non- 
existence in  them  of  fecal  matter  and  of  bile.  In  a  prognostic  point 
of  view,  the  most  colorless  evacuations  are  the  most  dangerous. 

The  presence  of  an  excessive  quantity  of  mucus  renders  the  dis- 
charges less  consistent  than  natural.  The  appearance  they  present  is 
similar  to  that  of  the  white  of  an  e^^ ;  or  the  whitish  masses  of  mucus 
surround  the  lumps  of  faeces,  or  are  intermingled  with  the  fluid  alvine 
discharges. 

Pus  in  large  amount  and  unmixed  with  faeces  is  discharged  only 
when  an  abscess  has  ruptured  into  some  part  of  the  intestine.  Stools 
composed  of  faeces  and  pus  are  encountered  in  chronic  inflammation 
and  in  ulceration  of  the  bowels  ;  and  whitish,  creamy  streaks  indicate 
the  presence  of  the  foreign  substance.  Yet  the  pus  may  be  so  inti- 
mately blended  with  the  faeces,  or  with  masses  of  mucus,  as  to  require 
the  microscope  for  its  detection. 

An  excess  of  hile  in  the  alvine  discharges  gives  rise  to  evacuations 
of  a  yellowish  brown  or  yellow  hue.  When  the  alimentary  tube  is 
highly  acid,  the  resulting  color  is  green.  Both  these  kinds  of  stools  are 
commonly  called  "  bilious  ;"  but  the  latter  is  less  absolutely  so  than  the 
former.  A  deficiency  of  bile  manifests  itself  by  clayey,  sometimes  even 
by  almost  white  stools.  Bile-pigment  is  not  found  in  healthy  stools. 
The  stools  may  contain  also  concretions  of  biliary,  pancreatic,  or  intes- 
tinal origin.  Sometimes  portions  of  neoplastic  growths  are  appreciable 
to  the  naked  eye.  A  curious  and  unusual  form  of  concretion  passing 
from  the  bowel  is  the  so-called  "  intestinal  sand."  It  resembles  de- 
posits of  uric  acid  or  urates,  but  does  not  respond  to  the  tests  for  uric 
acid,  as  I  have  had  occasion  to  note.  It  is  supposed  to  be  a  substance 
intermediate  between  the  ordinary  bile-pigments  and  stercobilin.^ 

^  Thomson  and  Ferguson,  Journal  of  Pathology  and  Bacteriology.  Feb.  1900. 

32 


510  MEDICAL  DIAGNOSIS. 

Black  stools  result  from  eating  certain  articles  of  food,  such  as 
blackberries ;  from  the  action  of  medicines,  as  iron,  bismuth,  man- 
ganese ;  from  a  vitiated  condition  of  the  bile  and  intestinal  secretions  ; 
or  from  the  effusion  of  blood  into  the  alimentary  canal.  At  all  events, 
when  the  hemorrhage  proceeds  from  the  stomach  or  the  upper  part  of 
the  canal,  the  stools  have  a  black,  tarry  appearance ;  when  from  the 
lower  section  of  the  tube,  pure  blood  is  passed,  or,  if  it  be  small 
in  quantity,  a  blood-streaked  mucus.  Should  any  doubt  exist  as  to 
whether  the  dark  discharges  be  dependent  upon  the  presence  of  blood, 
let  them  be  diluted  with  M^ater ;  they  will  assume  a  reddish  tinge  if 
this  be  the  cause  of  the  abnormal  color.  When  blood  pigment  is 
present,  it  is  in  the  form  of  hgematin. 

The  odor  of  the  evacuations  is  extremely  offensive  in  fevers  of  a 
low  type,  and  when  the  intestinal  secretions  are  vitiated,  or  bile  is  ab- 
sent. Acidity  of  the  intestinal  canal,  as  in  the  intestinal  catarrh  of 
children  and  of  adults,  or  in  rheumatism  or  gout,  imparts  to  the  stools 
a  sour  smell  and  an  acid  reaction.  The  reaction  in  health  varies  with 
the  food  ;  it  is  mostly  alkaline. 

In  cases  of  constipation  it  may  be  important  to  notice  the  shape  of 
the  passages,  because  this  may  show  whether  an  impediment  has  flat- 
tened or  otherwise  altered  them.  In  fevers,  as  well  as  in  affections  of 
the  intestinal  mucous  membrane,  whether  inflammatory  or  not,  we 
often  derive  information  from  studying  the  form  of  the  voided  matter. 
Figured  stools  succeeding  to  fluid  passages  are  always  of  favorable 
omen.  We  also  note  whether  the  stools  contain  masses  of  undigested 
matter  and  its  kind. 

Microscopical  examinations  of  the  fseces  are  not  often  made,  but 
they  may  be  of  great  service.  They  enable  us,  for  instance,  to  recog- 
nize with  certainty  that  the  yellowish  lumps  contained  in  the  evacua- 
tion, or  the  greasy  fllm  which  collects  upon  its  surface,  consist  of  fat. 
The  microscope,  too,  detects  masses  of  muscular  fibre,  of  elastic  tissue, 
of  starch-corpuscles,  of  fat,  coagulated  albumin,  crystals  of  cholesterin, 
red  corpuscles,  leucocytes,  and  various  fungoid  growths,  micro-organ- 
isms, and  parasites.  Among  the  animal  parasites,  besides  various, 
infusoria  and  worms, — the  main  variety  of  which  will  be  discussed 
farther  on  with  the  parasites, — we  find  the  amoeba  coli^  now  known  to 
be  the  chief  cause  of  tropical  dysentery.  It  is  one  of  the  rhizopods, 
varying  in  size  from  0.012  to  0.035  millimetre,  and  when  active  has  a 
characteristic  movement.  This  will  be  best  seen  if  the  stage  of  the 
microscope  be  kept  warm. 

The  microscope  exhibits,  in  the  fecal  discharges  of  all  diseases  in 
which  the  stools  readily  decompose,  masses  of  crystals  of  the  triple 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       511 

phosphates  ;  in  acrid  stools,  yeast  fungi ;  in  typhoid  fever,  shreds  of 
slough  from  the  enteric  ulcers,  and  bacilli ;  in  tubercular  ulceration  of 
the  bowel,  tubercle  bacilli ;  in  cholera,  comma  bacilli ;  and  under 
many  varying  conditions  both  in  the  faeces  and  in  different  organs,  as 
well  as  in  peritoneal  exudates  and  in  appendicitis,  the  baeillus  coli  com- 
munis. This  is,  as  a  rule,  a  sluggishly  moving  bacillus  which  grows 
readily  on  gelatin  plates,  the  surface  colonies  being  large  and  spherical 
and  of  a  dull  white.  It  is  stained  by  aniline  dyes,  but  is  decolorized 
when  treated  by  Gram's  method.  The  main  normal  ingredient  of 
fecal  matter  is  mucin.^  Phenol,  mdol,  and  scatol  are  common  con- 
stituents. Peptone  occurs  only  in  disease.^  One  drawback  to  the  use 
of  ohemieal  research  for  clinical  purposes  is  the  uncertain  composition 
of  the  fseces,  owing  to  the  number  of  elements  derived  from  the  food. 
A  large  amount  of  starchy  material  shows  deficiency  of  the  diastatic 
ferments  of  the  pancreatic  juice  in  the  salivary  glands. 

The  study  of  the  alvine  discharges  is  of  service  not  merely  in 
intestinal  complaints,  but  equally  in  the  many  maladies  in  which  the 
alimentary  tube  sympathizes  or  becomes  involved.  Ocular  inspection 
of  the  anal  region  may  disclose  the  existence  of  hemorrhoids,  fistulae, 
fissures,  or  prolapse,  and  digital  exploration  of  the  rectum  may  yield 
information  besides  as  to  the  presence  or  absence  of  ulceration, 
neoplasms,  stricture,  fecal  accumulation,  as  well  as  to  the  tone  of  the 
sphincter  and  the  sensiJ3ility  of  the  mucous  membrane,  and  also  as  to 
the  condition  of  contiguous  organs.  The  knowledge  thus  gained  is  sup- 
plemented or  confirmed  by  ocular  inspection  with  the  aid  of  specula. 
The  physical  condition  of  the  lower  bowel  may  be  investigated  fur- 
ther by  means  of  rectal  insufflation  of  air  or  gas,  or  injection  of  water. 

As  a  means  of  studying  intestinal  digestion,  especially  after  test 
meals  have  passed  from  the  stomach  into  the  duodenum,  the  ingeni- 
ous apparatus  of  Hemmeter^  may  be  employed.  The  contents  of  the 
duodenum  can  be  withdrawn  and  subjected  to  chemical  and  micro- 
scopical analysis.  The  activity  af  intestinal  digestion  and  absorption 
may  be  estimated  by  the  administration  of  two  or  three  grains  of 
iodoform  in  gelatin  capsules  hardened  with  formaldehyde  ;  with  gastric 
digestion,  absorption,  and  motility  normal,  the  saliva,  tested  with  chlo- 
roform and  nitric  acid,  will  ordinarily  yield  the  rose-red  reaction  of 
iodine  in  from  four  to  six  hours.^ 

^  Hoppe-Seyler,  Handbuch.  ^  Von  Jaksch,  Clinical  Diagnosis,  1899. 

^  Johns  Hopkins  Hospital  Medical  Bulletin,  April,  1895. 

*  Sahli,  Deutsche  Med.  Woch.,  1897,  No.  1  ;  Corresp.-bl.  f.  Scliw.  Aerzte,  1898, 
No.  10  ;  Deutsches  Archiv  f.  kUn.  Med.,  61.  B.,  5.  u.  6.  H.  ;  Lehrb.  d.  khn.  Unter- 
suchmeth.,  2d  ed.,  1899. 


512  MEDICAL  DIAGNOSIS. 

But  to  review  the  uncomplicated  intestinal  diseases,  grouping  them 
as  they  may  be  recognized  by  pain  and  peculiarity  in  the  fecal  dis- 
charges, and  descrilDing  with  them  the  affections  of  the  peritoneum. 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly 
to  the  Middle  or  Lower  Part  of  the  Abdomen,  and  not 
associated  with  marked  Tenderness  or  with  Fever. 

The  type  of  these  is  colic. 

Cohc. — This  is  an  intestinal  pain,  paroxysmal  in  its  character,  and 
usually  combined  with  constipation,  but  unattended  with  febrile  symp- 
toms. The  pain  is  of  a  severe  griping  or  twisting  kind,  is  commonly 
referred  to  the  neighborhood  of  the  umbilicus,  and  relieved  by  press- 
ure. Sometimes  there  is  soreness  with  the  pain,  and,  indeed,  a  slight 
soreness  not  infrequently  remains  after  the  paroxysm  has  passed  off. 
While  the  pain  lasts,  the  countenance  wears  an  anxious,  frightened 
expression ;  the  skin  is  cold ;  the  pulse  is  depressed.  Occasionally 
there  is  vomiting,  and  in  severe  cases  the  abdominal  walls  are  tense  or 
raised  in  hard  knots  by  the  spasmodic  contraction  of  the  muscles. 
An  attack  may  last  only  a  few  minutes,  or  for  several  hours. 

Some  persons  are  very  liable  to  attacks  of  colic.  Those  who 
suffer  from  indigestion,  or  are  enfeebled  by  exhausting  maladies,  are 
predisposed  to  them ;  so  also  are  hysterical,  gouty,  and  rheumatic 
individuals.  As  to  the  exciting  causes,  they  are  various  ;  and  some- 
what according  to  its  different  causes,  colic  presents  different  forms. 
Let  us  indicate  the  more  prominent. 

Colic,  simple  and  unconnected  with  a  disease  of  the  bowel. — hi  these 
cases,  generally  called  spasmodic  colic,  the  paroxysmal  pain  may  be  of 
diverse  origin.  It  may  be  the  result  of  direct  excitation  of  the  periph- 
eral intestinal  nerves  by  the  presence  of  irritating  substances  in  the 
canal,  such  as  indigestible  food,  cold  or  acid  drinks,  hardened  fseces, 
gases,  morbid  secretions,  ptomaines,  worms,  medicines,  or  poisons. 
It  may  proceed  from  an  irritation  of  the  central  nervous  system  re- 
flected to  the  intestinal  nerves.  It  may  be  sympathetic,  and  produced 
by  a  morbid  state  of  the  adjacent  abdominal  viscera. 

1.  Colic  owing  to  food  difficult  of  digestion  is  very  common,  espe- 
cially at  the  time  of  year  when  fruit  is  beginning  to  ripen.  It  may  be 
caused  by  food  taken  in  quantities  greater  than  the  digestive  organs 
can  assimilate.  Hence  it  is  frequent  in  children  at  the  breast  who  are 
overnourished,  and  in  persons  in  delicate  health  with  enfeebled  diges- 
tive powers.  The  form  of  colic  under  discussion  is  often  attended 
vdth  vomiting  and  diarrhoea ;  it  may  be  of  only  a  few  hours'  duration, 
or  it  may  last  for  several  days. 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       513 

Colic  arising  from  distention  of  the  intestines  witli  flatus,  or  "  flatu- 
lent colic,"  is  the  result  of  the  decomposition  of  food  in  the  alimentary 
canal ;  sometimes,  however,  the  gases  are  extricated  from  morbid  secre- 
tions, or  are  exhaled  directly  from  the  blood-vessels.  The  abdomen 
is  distended,  and  the  flatus  is  from  time  to  time  discharged,  with 
evident  relief.     Hysterical  persons  are  subject  to  this  form  of  colic. 

Colic  from  the  presence  of  morbid  secretions  in  the  intestinal 
canal  is  not  so  often  encountered  as  that  from  indigestilDle  food  or 
retained  fecal  matters.  Yet  it  is  occasionally  met  with  in  cases  of 
diarrhoea  attended  with  a  disordered  state  of  the  intestinal  functions  ; 
in  the  so-termed  bilious  colic  the  intestinal  pain  is  produced  by  the 
irritating  character  of  the  bile. 

This  bilious  colic  is  often  preceded  by  nausea,  loss  of  appetite, 
and  a  coated  tongue.  The  paroxysms  of  pam  frequently  go  hand  in 
hand  with  vomiting, — first  of  the  contents  of  the  stomach,  then  of  bile. 
They  are  in  general  accompanied  or  soon  followed  by  a  yellowish 
tinge  of  the  conjunctiva,  by  tenderness  in  the  region  of  the  liver,  and 
by  a  desire  to  go  to  stool.  The  bowels  are,  however,  apt  to  be  obsti- 
nately constipated.  Bilious  colic  is  common  in  malarious  districts  ; 
it  occurs  especially  during  the  summer  and  autumnal  months,  and 
frequently  follows  exposure.  It  sometimes  begins  with  a  chill,  and, 
unlike  the  other  forms  of  colic,  it  has  as  companions  febrile  excite- 
ment, and  a  full,  frequent  pulse.  Malarial  colic  may  occur  in  an 
epidemic  form.^ 

2,  In  the  second  class  of  cases  belong  colic  arising  from  fright 
from  anger,  that  happening  in  nervous  females  and  hypochondriac 
males,  perhaps  that  proceeding  from  sudden  exposure  to  cold,  the 
form  which  is  sometimes  seen  coexisting  with  neuralgic  pains  in  other 
parts  of  the  body ;  in  short,  all  those  cases  which  are  spoken  of  as 
nervous  colic.  The  attack  is  sudden,  and  not  commonly  of  long 
duration  ;  but  it  is  apt  to  be  repeated. 

The  "  metallic  coHcs"  are  further  instances  of  colic  produced 
through  agents  which  act  primarily  on  the  nervous  system.  This 
is  certainly  true  of  lead  colic.  Copper  colic  exliD^its  paroxysms  of 
severe  pain  like  those  caused  by  the  poisonous  influence  of  lead ;  but 
it  is  attended  with  nausea,  vomiting,  diarrhoea,  tenesmus,  an  abdomen 
distended  and  tender  to  the  touch, — in  other  words,  it  is  rather  an 
inflammation  of  the  intestine  with  colicky  pain  than  uncomplicated 
colic.  The  distinguishing  marks  of  lead  colic  are  the  bluish-gray  line 
along  the  gums  ;  the  contracted  abdomen  ;  the  obstinate  constipation  ; 

^  American  Journal  of  the  Medical  Sciences,  April,  1872. 


514  MEDICAL  DIAGNOSIS. 

the  great  relief  to  the  pam  usuahy  afforded  by  pressure  :  the  duration 
of  the  pam  ;  its  marked  and  agonizing  exacerbations  ;  and  the  history 
of  the  case.  The  signs  of  the  lead  poisoning  also  manifest  themselves 
m  other  jDarts  of  the  body. 

3.  Affections  of  various  organs  may  give  rise  to  colic,  by  sympathy, 
and  generally  through  irritation  reflected  through  the  nervous  system. 
Thus,  colic .  is  a  not  uncommon  attendant  on  morbid  states  of  the 
kidneys,  liver,  bladder,  testicles,  uterus,  or  ovaries,  and  on  disordered 
menstruation.  Yet  we  must  not  forget  that  the  pain,  although  sjDoken 
of  as  colic,  is  often  not  strictly  intestinal,  but  is  merely  a  pain  radiating 
from  the  affected  organs  themselves.  Again,  how  far  it  is  due  to 
neuritis  is  a  matter  to  be  taken  into  account. 

Colic  arising  in  consequence  of  some  abnormal  state  of  the  hoicel. — But 
colic  may  have  only  the  significance  of  a  symptom,  and  be  combined 
with  an  altered  structure  or  a  changed  position  of  the  intestine.  We 
meet,  indeed,  with  colicky  pains  in  dysentery  ;  enteritis  ;  hernia ;  ulcer- 
ation ;  intussusception  ;  strangulation  ;  twisting ;  strictures  ;  distention, 
— in  fact,  in  the  most  various  morbid  states  of  the  intestine.  And 
colic  as  a  symptom  can  be  discriminated,  as  far  as  the  pain  is  con- 
cerned, from  colic  as  an  idiopathic  disorder,  only  by  the  history  and 
the  concomitant  phenomena  of  the  case.  In  several  of  the  maladies 
cited  the  more  transitory  nature  of  the  pain, — or  gripings, — in  others 
the  presence  of  fever  and  of  tenderness,  serve  as  guides  in  diagnosis. 
Fever  and  soreness  to  the  touch  are  also  met  vAih.  in  that  form  of 
inflammation  of  the  bowel  which  happens  after  exposure,  or  after  the 
retrocession  of  rheumatism  from  some  external  part,  and  wliich  is 
commonly  known  as  rheumatic  or  inflammatory  colic. 

The  disorders  with  which  uncomplicated  colic,  or  that  which  is 
held  to  be  purely  spasmodic,  may  be  confounded,  are  : 

Gastralgia  ; 

Appendicitis  ; 

Perforation  of  the  Intestine  ; 

Strangulated  Hernia  ; 

Passage  of  Gall-Stones  ; 

Nephralgia  ; 

Spasm  of  the  Bladder  ; 

Uterine  Colic  ; 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves  ; 

Abdominal  Aneurism  and  Tumors  ;  Diseases  of  the  Spine  ; 

Enteritis  and  Peritonitis. 

Gastralgia. — In  gastralgia  the  pain  is  seated  in  the  epigastric 
region ;  whereas  in  colic,  or  enteralgia,  the  pain  is  near  the  umbilicus. 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       515 

or  rapidly  shifts  its  position  from  this  point  to  different  parts  of  the 
abdomen,  and  is  often  connected  with  a  spasmodic  contraction  of  the 
abdominal  muscles.  Again,  the  history  in  cases  of  gastralgia ;  the  fact 
that  the  attacks  happen  most  frequently  after  meals  ;  their  association 
with  signs  of  a  disordered  stomach, — indicate  the  organ  m  which  the 
pain  arises.  And  much  the  same  general  signs,  in  addition  to  the 
marked  constipation  and  the  visible  movements,  enable  us  to  distin- 
guish those  instances  of  peristaltic  disturbance  of  the  stomach  to  which 
Kussmaul  ^  has  called  attention,  and  in  which  the  drawing  pain  is  apt 
to  be  referred  to  the  intestine :  indeed,  the  peristaltic  disorder  may 
spread  to  it. 

Appendicitis. — The  sudden  and  sharp  pain  of  appendicitis,  occurring 
in  paroxysms  and  often  following  acute  digestive  disorders,  is  very  apt 
to  be  mistaken  for  colic.  But  the  seat  of  the  pain,  which  is  generally 
in  the  right  iliac  fossa  and  which  becomes  associated  with  tenderness 
and  with  fever,  tells  us  the  condition  we  are  dealing  with. 

Perforation  of  the  Intestine. — When  paroxysms  of  pain  have  their 
origin  in  perforation  of  the  intestine,  the  extreme  prostration  and  col- 
lapse show  that  they  are  not  produced  by  a  harmless  disorder  like 
colic.  Further,  the  abdominal  distress  is  in  most  cases  preceded  by 
symptoms  of  a  diseased  state  of  the  stomach  or  the  intestines,  of 
appendicitis  or  of  typhoid  fever ;  and  if  the  patient  live  sufficiently 
long  after  the  accident,  the  pain  is  followed  by  distention  of  the  abdo- 
men and  extreme  tenderness, — in  fact,  by  the  signs  of  peritonitis. 
However,  the  differential  diagnosis  is  occasionally  very  difficult.  A 
valuable  sign  of  perforation  and  of  air  in  the  peritoneum  is  the  ob- 
literation of  the  dulness  on  percussion  over  the  hepatic  region,  pointed 
out  by  Alonzo  Clark. 

Strangulated  Hernia. — All  mechanical  obstructions  of  the  intestine 
will  lead  to  paroxysms  of  intestinal  pain.  They  are  met  with  in  cases 
of  intussusception  and  of  ileus ;  they  are  also  frequent  in  cases  of 
strangulated  hernia.  In  all,  the  obstinate  constipation  should  arouse 
suspicion  regarding  the  true  nature  of  the  complaint.  To  detect  a 
hernia  a  local  examination  is  required  ;  and,  therefore,  a  careful  search 
at  the  usual  seats  of  this  affection  ought  to  be  made  in  every  instance 
of  severe  or  protracted  colic.  Lives  have  been  lost  in  consequence  of 
the  neglect  of  this  simple  precaution  against  disastrous  error. 

Passage  of  Gail-Stones. — The  passage  of  a  gall-stone  is  generally 
attended  with  paroxysms  of  intense  pain  which  are  readily  mistaken 
for  colic.     There  is,  as  a  rule,  the  same  absence  of  fever  and  of  ten- 

^  Sammlung  klinisclier  Vortriige,  No.  181,  June,  1880. 


516  MEDICAL  DIAGNOSIS. 

derness  ;  yet  fever  of  short  duration  does  happen.  Pressure  is  often 
resorted  to  in  order  to  mitigate  the  suffering,  and  thus  the  resemblance 
to  cohc  is  lieightened.  The  points  of  distinction  from  coKc  are,  tlie 
position  of  the  pain  in  the  epigastric  region ;  the  severe  nausea  and 
vomiting  attending  the  attack ;  tlie  jaundice ;  and  the  voiding  of  gall- 
stones with  the  stools.  The  latter  sign,  though  a  positive  one,  assists 
less  in  the  discrimination  of  the  disorder  than  would  appear  at  first 
sight ;  partly  because  it  does  not  serve  as  a  means  of  indicating  the 
nature  of  the  affection  until  its  close,  partly  because  the  calculus  often 
escapes  detection  in  the  feeces.  The  best  way  to  find  it  is  to  pass  the 
evacuations  through  a  sieve ;  this  is  more  certain  than  covering  the 
discharge  with  water.  The  stone  may  not  come  from  the  bowels  for 
some  days  after  the  attack  of  colic.  Its  passage  gives  rise  to  symp- 
toms like  those  of  bilious  colic.  The  repetition  of  the  attack  is  always 
a  strong  reason  for  suspecting  it  to  be  owing  to  a  discharge  of  a  calcu- 
lus from  the  gall-bladder ;  and  so  are  severe  retching  and  vomiting, 
sudden  supervention  of  jaundice,  and  localized  epigastric  pain.  He- 
patic neuralgia^  if  there  be  such  a  disease,  cannot  be  discriminated 
from  gall-stone  colic,  except  by  its  recurrence  after  certain  intervals, 
the  alternations  with  other  affections  of  the  nervous  system,  and  the 
slightest  touching  of  the  part  inducing  at  times  the  acute  pains. ^ 

Sometimes  gall-stones  are  closely  simulated  by  impacted  faeces,  the 
pressure  of  which  occasions  colicky  pains,  and  even  jaundice.  A 
dose  of  oil  brings  away  the  hardened  faeces.  The  swelling  in  the  right 
side  may  be  sometimes  readily  detected.  Among  the  rarer  symptoms 
attending  or  following  the  passage  of  gall-stones,  temporary  dilatation 
of  the  heart  and  tricuspid  regurgitation  have  been  noticed.^ 

Where  the  gall-stones  are  large  and  have  become  impacted  in  their 
course  towards  the  intestine,  they  give  rise  to  inflammation  which  may 
lead  to  ulceration  and  to  the  discharge  of  the  concretion — generally 
then  very  large — into  the  intestine  or  stomach.  Subsequently  an  ob- 
literation of  the  duct  may  happen  ;  or  the  inflammation  and  ulceration 
of  the  duct  may  result  in  perforation  into  the  peritoneum.  In  some 
cases  the  gall-stones  are  voided  through  the  abdominal  walls,  in  con- 
sequence of  their  having  caused  inflammation  of  the  gall-bladder  and 
subsequent  adhesions  to  the  abdominal  parietes.  The  fistulous  pas- 
sages discharge  pus  and  bile,  and  occasionally  fresh  stones  :  they  may 
last  for  years,  but  in  time  tliey  generally  heal. 

'  See  the  cases  of  Budd,  on  Diseases  of  the  Liver  ;    of  Andral,  Clinique  Medi- 
cale,  tome  ii.  ;  and  of  Frerichs,  Diseases  of  the  Liver. 

^  Potain,  quoted  by  See,  Maladies  du  Coeur,  Paris,  1883. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       517 

Nephralgia. — Paroxysms  of  pain  with  intervals  of  comparative  ease 
and  miassociatecl  with  fever  occur  in  nephralgia,  and  are  often  mis- 
taken for  colic.  Now,  kidney  pain  is  generally,  although  not  invariably, 
caused  by  the  passag'e  of  a  calculus  through  the  ureter.  Its  symp- 
toms, besides  the  pain,  are  numbness  of  the  thigh,  nausea  and  vomit- 
ing, a  constant  desire  to  make  water,  and  aching  and  drawmg  up  of 
the  testicle.  The  patient,  as  in  colic,  is  restless,  and  seeks  relief  by 
frequently  changing  his  position.  The  pain  comes  on  suddenly,  and 
is  excruciating.  It  is  felt  in  the  loins,  usually  on  one  side,  and  shoots 
along  the  track  of  the  ureter  to  the  hip  and  thigh,  or  extends  to  the 
umbilicus  ;  it  is  often  associated  with  tenderness  in  the  course  of  the 
ureter.  Occasionally  it  is  almost  exclusively  felt  at  the  hip.  When 
the  stone  reaches  the  bladder,  the  pain  ceases  as  abruptly  as  it  began ; 
though  sometimes  there  is  still  discomfort  produced  by  the  stone  in- 
terfering with  the  act  of  micturition.  During  the  attack  the  urine  is 
passed  in  small  quantities  at  a  time.  It  is  high-colored ;  sometimes  it 
contains  a  little  blood.  If  it  be  collected,  after  all  pain  has  disappeared, 
and  be  carefully  examined,  a  small,  hard  body  or  a  sandy  deposit  is 
generally  detected,  and  reveals  the  cause  of  the  past  anguish.  It  is 
from  the  presence  of  the  sandy  deposit  that  the  complaint  has 
received  popularly  the  name  of  a  fit  of  "  the  gravel. '' 

The  seat  of  the  pain  is  a  chief  distinction  from  intestinal  colic ;  yet 
in  neither  complaint  is  the  seat  entirely  characteristic.  It  is  not  always 
strictly  umbilical  in  colic  ;  it  is  not  always  exactly  in  the  region  of  the 
ureter  or  kidney  in  nephralgia.  Of  more  importance  is  the  state  of 
the  urinary  functions,  which  are  comparatively  undisturbed  in  colic. 
Again,  the  numbness  of  the  thigh  and  the  retraction  of  the  testicle  are 
valuable  diagnostic  marks  ;  they  would  be  absolutely  decisive  were 
they  constantly  present  in  nephralgia. 

Sjmsm  of  the  Bladder. — The  bladder  is  sometimes  the  site  of  par- 
oxysms of  violent  pain,  supposed  to  attend  upon  a  spasm  of  the  viscus. 
There  is  an  intense  desire  to  urinate,  which  the  passing  of  water  does 
not  allay.  The  pain  is  accompanied  by  a  sense  of  constriction  at  or 
near  the  pelvis,  and  sometimes  by  tenesmus,  and  may  extend  to  the 
kidneys,  to  the  thighs,  and  to  the  sacrum ;  or  the  irritation  may  be 
communicated  to  the  penis,  and  cause  erections.  If  the  sphincters  be 
involved  the  urine  cannot  be  voided.  The  bladder  distends  ;  there  is 
intense  anxiety,  with  restlessness  ;  the  pulse  is  feeble  ;  the  skin  is  cold, 
and  covered  with  clammy  perspiration. 

A  spasm  of  the  bladder  may  be  caused  by  the  presence  of  a  stone 
or  of  irritating  urine.  It  is  also  encountered  in  gout  and  hysteria,  and 
as  the  result  of  stimulating  diuretics.     Violent  fright,  too,  may  occasion 


518  MEDICAL  DIAGNOSIS. 

it.  It  sometimes  proceeds  from  a  disorder  of  ad.iacent  structures,  as 
of  the  rectum  or  of  the  uterus.  Now  and  then  it  is  associated  with 
inflammation  or  suppuration  of  the  kidney,  and  the  vesical  pain  is  so 
intense  that  it  withdraws  attention  from  the  organ  most  affected.  To 
distinguish  it  from  coKc  is  not  difficult ;  the  loca.tion  of  the  pain  and 
the  disturbed  condition  of  the  urinary  functions  serve  as  guides.  It 
resembles  nephralgia  more  closely. 

Uterine  Colic. — The  painful  sensations  experienced  by  some  women 
at  their  menstrual  periods  may  come  on  in  paroxysms  similar  to  those 
of  colic.  In  truth,  the  pain  is  often  spoken  of  as  uterine  cohc,  and  at 
times  continues  for  many  days,  persisting  during  the  menstrual  period, 
or  even  longer.  In  some  of  these  cases  the  complaint  is  localized  in 
the  uterus ;  in  others,  in  the  ovaries,  which  are  then  tender  to  the 
touch. 

Now,  with  reference  to  the  disorder  first  mentioned,  or  ordinary 
dysmenorrhoea,  it  may  be  easily  discriminated  from  colic  by  its  occur- 
rence with  the  setting  in  of  the  menstrual  flow ;  by  the  pain  remitting 
rather  than  intermitting ;  by  the  seat  of  the  pain  in  the  pelvis,  or  the 
lower  part  of  the  abdomen ;  by  its  not  uncommon  association  with 
nausea  and  vomiting ;  and  by  the  fact  that  all  the  signs  of  disordered 
menstruation  have  happened  previously  at  the  periods. 

Where  the  ovaries  are  much  congested  or  inflamed,  whether  or  not 
the  affection  exist  in  connection  with  dysmenorrhoea,  or  occur  in  con- 
sequence of  other  causes,  among  which  gonorrhoea  may  be  one,  the 
pain,  tenderness,  and  swelling  in  the  hypogastric  region ;  the  numb- 
ness and  flexed  position  of  one  or  both  thighs  ;  the  febrile  irritation, 
and  the  hysterical  symptoms  ;  the  retention  of  the  urine  ;  the  violence 
of  the  paroxysms  of  pain,  and  the  duration  of  the  malady, — form  a 
group  of  phenomena  very  dissimilar  to  those  of  ordinary  cases  of  colic. 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves ;  Abdominal  Neural- 
gia.— The  dorsal  and  lumbar  nerves  are  subject  to  neuralgic  affec- 
tions, which  exhibit,  like  colic,  paroxysms  of  pain  unaccompanied  by 
fever.  But  Valleix  has  taught  us  to  look  for  spots  painful  to  the 
touch  in  the  course  of  the  aching  nerves,  and  has  shown  that  the 
disturbance  of  the  nerves  supplying  the  abdominal  parietes  manifests 
itself  on  one  side  of  the  body  only,  whereas  an  irritation  of  the  intes- 
tinal nerves  obeys  no  such  law. 

In  neuralgia  of  the  lumbar  nerves,  or  lumbo-abdominal  neuralgia^ 
the  pain  is  commonly  felt  in  the  hypogastric  region,  a  little  to  one  side 
of  the  median  line.  In  this  situation,  too,  there  is  localized  soreness 
on  pressure ;  the  other  tender  spots  are,  generally,  one  a  little  to  the 
outside  of  the  first  or  second  lumbar  vertebra,  and  one  immediately 


DISEASES  OF  THE  INTESTINES  AND   PERITONEUM.       519 

above  the  middle  of  the  crest  of  the  ihum.  In  women,  who  are  by 
far  the  greatest  sufferers  from  the  disease,  there  is  sometimes  also  a 
painful  place  about  the  middle  of  the  Fallopian  tube,  or  on  the  neck 
of  the  uterus  ;  in  men,  a  point  on  the  scrotum  here  and  there  is  found 
sore  to  the  touch.  These  spots  of  tenderness  serve  as  characteristic 
signs ;  and  they  enable  us  to  separate  neuralgia  not  only  from  colic, 
but  also  from  lumbago,  and  from  rheumatism  of  the  abdominal  walls. 

Besides  these  forms  of  neuralgia  we  find  other  kinds  of  abdominal 
neuralgia,  which  may  be  mistaken  for  cohc.  They  are  attacks  of  pain 
of  great  severity,  affecting  especially  the  mesenteric  plexus  or  the 
solar  plexus,  and  attended  with  a  sense  of  faintness  and  annihilation. 
The  disorder  is  often  excited  by  exertion,  is  associated  with  debility, 
and  relieved  by  an  antineuralgic  treatment.  In  some  cases  it  is  of 
malarial  origin ;  and  in  every  instance  we  must  lay  stress  on  the 
frequent  recurrence  of  the  pain  and  on  the  history  to  enable  us  to 
discriminate  between  the  neuralgic  complaint  and  colic.  The  dis- 
tinction from  gastralgia  can  be  made  only  by  the  more  marked  gastric 
symptoms,  and  by  the  absence  of  marked  prostration  and  sense  of 
fainting  in  this  malady.^ 

Angioneurotic  CEdema. — The  local  oedematous  swellings  of  passing 
character  met  with  in  this  disease  are  generally  associated  with  attacks 
of  severe  colic,  nausea,  and  vomiting.  In  recurring  purpura  the  same 
occurrences  are  met  with. 

Abdominal  Aneurism  and  Tumors ;  Diseases  of  the  Spine. — In  all 
of  these  we  may  find  violent  pain  of  a  paroxysmal  kind  referred  to 
various  portions  of  the  abdomen,  and  unaccompanied  by  fever.  We 
judge  that  the  pain  is  not  colic  by  its  frequent  repetition ;  by  its  want 
of  association  with  intestinal  or  gastric  disturbance ;  by  its  being, 
although  liable  to  exacerbations,  so  steadily  present  at  some  part  either 
of  the  spine  or  of  the  abdomen  ;  and  by  the  attending  symptoms  and 
signs  occasioned  by  an  abdominal  tumor,  or  by  a  disease  of  the  lower 
dorsal  or  of  the  lumbar  vertebrae. 

Enteritis  and  Peritonitis. — Inflammations  of  the  intestines  and  of 
the  peritoneum  also  give  rise  to  severe  abdominal  pain.  But  it  is 
more  constant,  and  is  linked  to  great  tenderness,  and,  in  acute  cases, 
to  symptoms  of  high  febrile  excitement.  Thus  enteritis  and  perito- 
nitis belong  to  a  different  group  of  diseases, — a  group  of  inflammatory 
affections,  which  I  shall  now  describe. 


'  A  number  of  cases  of  abdominal  neuralgia  are  reported  by  Handfield  Jones 
in  his  Treatise  on  Functional  Nervous  Diseases  ;  and  by  Porcher  in  American 
Journal  of  the  Medical  Sciences,  July,  1869. 


520  MEDICAL  DIAGNOSIS. 

Diseases  attended  with  Pain  and  Marked  Tenderness  in  the 
Umbihcal  Region  or  diffused  over  the  Abdomen. 

Acute  Enteritis. — Enteritis  means,  by  common  consent,  inflam- 
mation of  the  small  intestine,  especially  of  the  portion  that  lies  be- 
tween the  duodenum  and  the  colon.  The  morbid  process  may  extend 
to  the  colon ;  if,  however,  it  involve  a  large  portion  of  the  latter,  it  is 
colitis  or  dysentery.  There  are  two  forms  of  enteritis  ;  one  in  which 
the  mucous  membrane  of  the  bowel  is  alone  affected, — muco-enteritis 
or  intestinal  catarrh.  In  the  second,  more  than  the  mucous  tunic  is 
implicated ;  there  is  also  inflammation  of  the  submucous  and  muscu- 
lar coats,  or  even  of  the  serous  investment  of  the  bowel.  To  this 
variety  of  the  complaint  the  term  enteritis  is  by  several  writers  re- 
stricted ;  and  it  is  to  this  rare  form  of  the  malady,  a  phlegmonous  en- 
teritis, occurring  acutely,  that  the  description  about  to  be  given  more 
particularly  applies. 

The  symptoms  of  an  acute  attack  of  enteritis  are  those  of  colic, 
attended  with  fever  and  tenderness.  The  disorder  may  begin  Avith 
the  symptoms  of  colic,  or  it  may  set  in  with  chill  and  fever.  When 
the  disease  is  fully  established  the  fever  runs  high  ;  the  pulse,  tense 
and  full  at  the  onset,  becomes  small  and  wiry.  There  are  nausea 
and  vomiting,  and  sometimes  distressing  flts  of  retching.  The  tongue 
is  covered  with  a  white  coat,  or  is  red  and  dry.  The  bowels  are  con- 
stipated ;  sometimes  there  is  diarrhoea,  or  constipation  alternating 
with  diarrhcEa.  The  stools  may  contain  a  small  quantity  of  blood ; 
they  rarely  contain  pus.  The  appetite  is  lost,  the  thirst  great.  The 
pain,  as  iq  colic,  is  paroxysmal.  It  begins  near  the  umbilicus,  and 
thence  may  shift  to  various  parts  of  the  abdomen,  but  not  to  the  epi- 
gastrium ;  it  does  not  cease  as  in  colic,  but  rather  exacerbates,  and 
then  changes  to  a  dull  feeling  of  distress.  It  is  greatly  increased  by 
pressure,  and  the  patient  seeks  relief,  as  in  peritonitis,  by  lying  on  his 
back  with  his  thighs  flexed,  so  as  to  relax  the  abdominal  muscles. 
Towards  the  right  of  the  umbilicus  it  is  not  uncommon  to  find  a 
marked  pulsation,  from  throbbing  of  the  abdominal  aorta  or  of  its 
large  branches, — a  sign  to  which  Stokes^  directed  attention.  This 
pulsation  may  be  very  annoying.  In  looking  over  the  notes  of  my 
cases  on  which  the  description  of  the  symptoms  of  enteritis  just  given 
is  based,  I  find  one  in  which  neither  the  thirst,  nor  the  pain,  nor 
the  nausea  and  vomiting  occasioned  as  much  distress  as  the  violent 
throbbing  in  the  abdomen. 

^Article  "Enteritis,"  in  Cyclopaedia  of  Practical  Medicine. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.      52] 

In  the  instances  of  the  malady  that  advance  to  a  fatal  termina- 
tion, the  pulse  becomes  cjuick  and  irregular ;  hiccough  appears  ;  the 
abdomen  swells  ;  the  features  are  haggard ;  and  the  patient's  strength 
becomes  gradually  exhausted.  The  worst  and  most  hopeless  cases 
of  the  disease  are  those  dependent  on  mechanical  obstruction  of  the 
bowel,  whether  it  proceed  from  organized  bands  in  which  a  loop  of 
intestine  is  caught,  or  from  invagination,  or  from  accumulation  of 
hardened  faeces,  or  from  a  hernial  strangulation.  The  disease  may 
lead  to  purulent  infiltration  of  the  submucous  tissue  and  to  abscess- 
formation. 

Among  the  symptoms  of  enteritis,  pain  is  one  of  the  most  impor- 
tant. It  is  never  absent,  save  in  rare  instances  in  which  the  mflam- 
mation  is  very  intense  at  the  onset.^  Still  more  important  is  the 
great  tenderness.  This  enables  us  to  say  that  the  case,  in  spite  of 
the  colicky  pains,  is  not  colic.  It  warns  us  not  to  administer  strong 
cathartics  to  overcome  the  constipation  that  appears  in  consequence 
of  the  severe  inflammation. 

The  disease  in  its  violent  form  just  described  bears  a  close  re- 
semblance to  peritonitis  :  we  shall  presently  see  what  are  its  distin- 
guishing marks.  But  there  is,  as  above  stated,  another  variety  of  the 
disease,  a  mild  variety,  or  muco-enteritis,  in  which  the  disturbance  is 
limited  to  the  mucous  membrane.  The  main  features  of  this  intes- 
tinal catarrh  are  the  same,  but  they  stand  out  in  less  bold  relief. 
There  are  griping  pains,  a  slight  soreness  to  the  touch,  general  un- 
easiness, loss  of  appetite,  thirst,  nausea,  and  sometimes  vomiting. 
But  we  find  only  slight  fever ;  and  the  febrile  excitement  remits  in 
the  morning.  Diarrhoea  is  present,  and  the  stools  are  sometimes 
very  offensive.  This  form  of  the  disease  may  terminate,  as  the 
severer  inflammation  generally  does,  in  less  than  a  week  ;  yet  it  may 
persist  for  several  weeks,  and  thus  gradually  lapse  into  a  chronic 
complaint.  It  is  common  in  children,  especially  during  dentition.  It 
is  also  observed  when  irritating  food  or  secretions  occupy  the  aliment- 
ary canal  for  any  length  of  time,  or  after  exposure  to  cold  and  damp, 
particularly  when  the  skin  is  perspiring  freely,  and  as  an  attendant 
upon  the  exanthemata.  It  resembles  typhoid  fever,  Indeed,  it  is 
sometimes  difficult,  especially  in  children,  or  in  the  intestinal  catarrh 
of  catarrhal  fever,  to  know  whether  we  are  dealing  with  a  case  of 
simple  intestinal  catarrh  or  with  the  intestinal  symptoms  of  enteric 
fever.  The  state  of  the  cerebral  functions,  the  pain  and  gurgling  in 
the  iliac  fossa,  and  the  high  temperature  in  the  latter  malady,  may 

^  Andral,  Pathologie  interne,  tome  i.  p.  47.  » 


522  MEDICAL  DIAGNOSIS. 

clear  up  the  doubt ;  yet  in  some  cases  nothing  but  the  eruption  and 
the  results  of  the  Widal  test  will  do  so. 

The  symptoms  just  described  belong  to  catarrh  of  the  ileum,  or 
of  the  ileum  and  the  ascending  colon.  In  catarrhal  inflammation  of 
the  duodenum  there  is  often  constipation  in  place  of  diarrhoea.  Pain 
between  two  and  three  hours  after  the  taking  of  food,  loss  of  appetite, 
coated  tongue,  fetid  breath,. marked  digestive  disorder,  flatulency,  and 
jaundice  are  prominent  among  the  symptoms.  The  pain  is  apt  to 
come  on  in  paroxysms  like  gastralgia,  although  referred  somewhat 
lower  than  the  stomach  ;  these  seizures  last  several  hours,  and  slowly 
subside.  We  frequently  find  a  certain  amount  of  soreness  developed 
by  deep  pressure  in  the  right  hypochondrium  and. the  upper  part  of 
the  umbilical  region.  There  is  weakness,  with  much  despondency,  and 
slight  elevation  of  temperature.  An  acute  attack  lasts  two  or  three 
Aveeks.     In  the  chronic  form  the  duration  may  be  as  many  months. 

Another  affection  which  is  liable  to  be  mistaken  both  for  enteritis 
and  for  typhoid  fever  has  been  described  by  Klob.^  The  chief  symp- 
toms are  violent  pains  in  the  hypogastric  region,  with  vomiting,  thready, 
frequent  pulse,  high  temperature,  and  the  rapid  supervention  of  som- 
nolence and  coma.  In  some  instances  hemorrhages  happen.  Hem- 
orrhagic erosions  are  found  in  the  stomach,  and  bloody  infiltrations  in 
the  jejunum;  the  parenchyma  of  the  mesenteric  glands,  their  lym- 
phatics, and  the  thoracic  duct  are  infiltrated  with  blood ;  the  spleen 
is  enlarged.  The  disorder  shows  then  a  striking  hemorrhagic  ten- 
dency, and  is  supposed  to  be  a  blood-affection  similar  to  pseudo- 
leukaemia. 

A  croupous  or  diphtheritic  enteritis  is  not  seen  save  as  a  second- 
ary process,  if  we  except  the  instances  in  which  it  follows  poisoning 
by  mercury,  by  arsenic,  or  by  lead.  It  is  more  generally  encountered 
as  a  secondary  affection  in  some  infectious  diseases,  as  in  pneumonia, 
pyaemia,  typhoid  fever ;  or  in  cancer,  Bright's  disease,  or  cirrhosis  of 
the  liver.  Its  symptoms  may  be  latent,  but  generally  there  are  diar- 
rhoea and  pain  without  tenesmus. 

Acute  Peritonitis. — As  in  acute  enteritis,  so  in  acute  peritonitis, 
pain  and  tenderness  are  the  most  significant  symptoms.  To  these  are 
joined  fever,  distention  of  the  abdomen,  and,  frequently,  cold  sweats, 
nausea,  vomiting,  and  obstinate  constipation.  The  disease  begins 
with  chilly  sensations  or  protracted  rigor.  To  these  succeed  fever, 
and  abdominal  pain  and  distention.  The  fever  runs  high  at  the 
onset ;  it  exhibits  a  dry,  burning  skin,  an  axillary  temperature  of  103° 

1  Wien.  Med.  Zeitung,  quoted  in  Lond.  Med.  Record,  Feb.  1875. 


DISEASES   OF   THE  INTESTINES  AND  PERITONEUM.       523 

and  upward,  a  pulse  frequent,  but,  as  in  acute  inflammations  of  the 
mucous  and  serous  membranes  below  the  diaphragm,  small  and  wiry. 
However,  both  the  character  of  the  pulse  and  that  of  the  skin  change 
as  the  malady  progresses.  The  pulse  is  less  tense  and  more  de- 
veloped as  the  inflammation  subsides,  or  feeble  and  flickering  if  the 
disorder  proceed  towards  a  fatal  termination.  The  skin  is  frequently 
covered  with  cold  sweats.  The  temperature  is  irregular,  and  may 
sink  below  the  normal.  The  features  are  sharpened  and  wear  the 
look  of  death,  even  in  cases  which  ultimately  recover. 

The  pain  is  constant  and  severe.  It  may  exacerbate,  but  it  never 
intermits.  At  first  the  pain  is  confined  to  a  particular  point ;  but  as 
the  inflammation  extends,  so  it  extends  over  the  whole  abdomen.  It 
is  increased  by  the  slightest  pressure,  be  that  pressure  exerted  by  the 
hand  or  by  movements  of  any  kind.  To  obviate  the  pressure,  the 
patient  lies  on  his  back  with  his  thighs  flexed,  and,  however  tired  of 
retaining  the  same  position,  he  does  not  change  it.  The  descent  of 
the  diaphragm  augments  the  pain  :  instinctively,  therefore,  he  refrains 
from  drawing  long  breaths,  and  his  respiration  is  short  and  frequent 
and  purely  thoracic. 

The  abdominal  distention  is  in  part  owing  to  meteorism,  in  part  to 
the  liquid  effused  into  the  peritoneum.  Percussion  tells  us  in  indi- 
vidual cases  how  far  each  factor  acts  as  a  cause  of  the  enlargement 
by  the  tympanitic  or  the  dull  sound  elicited.  Palpation,  too,  reveals 
the  presence  of  liquid.  Yet  percussion  or  palpation  ought  to  be  em- 
ployed only  with  the  greatest  care,  on  account  of  the  pain  they  occa- 
sion. The  fluid  does  not  gravitate  as  invariably  as  in  ascites  to  the 
lower  portion  of  the  belly.  It  is  often  caught  in  sacs  formed  by  the 
membrane  adhering  in  spots  ;  and  thus  circumscribed  dulness  may  be 
found  at  one  or  several  parts  of  the  abdomen.  Sometimes  the  rough- 
ening of  the  membrane  gives  rise  to  a  distinct  friction  sound. 

Independently  of  the  abdominal  pain  and  swelling,  we  meet,  in 
acute  peritonitis,  with  constipation,  nausea  and  vomiting,  headache, 
a  suppression  of  the  urinary  discharge,  and  in  rare  instances  with 
priapism ;  of  these  symptoms,  constipation  is  the  most  constant. 
It  is  caused  by  the  paralyzed  state  of  the  intestine,  to  portions  of 
which  the  inflammation  may  spread ;  or  by  the  lymph  gluing  to- 
gether the  coils  of  the  bowels. 

Death  in  acute  peritonitis  is  commonly  preceded  by  enormous 
tumefaction  of  the  belly,  cold  sweats,  a  pinched  countenance,  and  a 
rapid,  flickering  pulse.  When  recovery  takes  place — unfortunately  a 
rarer  issue  of  the  malady  than  its  fatal  termination — it  is  very  slow 
and  gradual :    and  often   morbid   conditions   remain   which   prolong 


524  MEDICAL  DIAGNOSIS. 

greatly  the  patient's  illness,  and  may  lead  in  themselves  to  a  disastrous 
result.  It  is,  therefore,  impossible  to  foretell  the  duration  either  of  the 
acute  disease  or  of  its  consequences. 

Acute  peritonitis  arises  idiopathically  from  exposure  to  cold  and 
wet  only  very  occasionally  ;  much  oftener  in  consequence  of  injuries  to 
the  abdomen,  such  as  blows,  stabs,  or  kicks ;  or  from  perforation  or 
laceration  of  some  of  the  abdominal  organs,  such  as  perforative  ulcer 
of  the  stomach,  intestine,  appendix,  or  gall-bladder,  and  discharge  of 
their  contents  into  the  peritoneal  cavity,  or  from  a  ruptured  tubal 
pregnancy.  Uterine  injections  passing  into  the  peritoneal  cavity  may 
cause  peritonitis.  It  also  results  from  rheumatism,  or  from  a  poisoned 
state  of  the  blood,  or  from  acute  tuberculosis,  or  from  Bright's  disease. 
It  sometimes  originates  from  an  inflammation  of  the  abdominal  viscera, 
especially  of  the  spleen,  intestines,  or  uterus  and  its  appendages, 
spreading  to  their  serous  covering.  Again,  other  morbid  states  of  the 
abdominal  organs,  such  as  cysts  of  the  ovaries,  intestinal  intussuscep- 
tion, or  strangulated  hernia,  may  compress  or  irritate  the  membrane, 
and  lead  to  inflammatory  action. 

Perforative  peritonitis  is  characterized  by  its  sudden  development. 
Most  frequently  perforation  of  the  stomach  or  intestine  or  appendix 
lies  at  the  bottom  of  the  mischief,  and  many  of  the  cases  are  met 
with  in  typhoid  fever,  or  in  disease  of  the  gall-bladder,  or  in  salpui- 
gitis.  Whatever  its  cause,  the  perforation  is  attended  with  severe 
pain,  sometimes  with  a  chill,  and  is  immediately  followed  by  collapse  ; 
tenderness  and  distention  of  the  abdomen,  and  shallow  breathing, 
vomiting,  and  rise  of  temperature  soon  make  their  appearance.  The 
swelling  of  the  abdomen  is  great,  and  the  gas  in  the  peritoneal  cavity 
occasions  tympanitic  resonance  over  the  liver  and  spleen,  obliterating 
the  normal  dulness  of  these  organs.  In  very  rare  instances  the  con- 
tents of  the  alimentary  canal  may  be  discharged  into  the  sac  without 
giving  rise  to  inflammation.^ 

The  peritonitis  of  childbed  fever,  or  puerj^eral  peritonitis^  is  in  its 
symptoms,  so  far  as  the  peritoneal  inflammation  is  concerned,  not 
different  from  those  of  any  other  kind  of  peritonitis,  except  that 
diarrhoea,  instead  of  constipation,  is  often  present.  The  disease  is 
generally  ushered  in  by  chills.  The  temperature  rises  speedily  to  a 
considerable  height,  to  104°  or  105°,  and  continues  high  with  irregu- 
lar remissions.     It  is  in  the  region  of  the  uterus  or  the  uterine  appen- 

^  Cases  reported  by  Bardeleben  and  Siebert,  quoted  in  Henocli's  Clinic  of 
Abdominal  Diseases.  I  have  met  with  several  instances  of  the  kind  in  typhoid 
fever. 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       525 

dages  that  pain  and  tenderness  are  first  felt.  But,  independently  of 
the  symptoms  of  the  local  disorder,  there  are  evidences  of  a  septi- 
csemia ;  we  And  delirium,  black  vomit,  exudation  into  the  pericardium 
and  pleura.  Fortunately,  the  diagnosis  is  one  we  are  now  less  and 
less  often  called  upon  to  consider,  for  antisepsis  has  almost  put  a  stop 
to  the  disease. 

Partial  or  local  peritonitis  is  almost  invariably  owing  to  a  pre- 
existing morbid  condition  of  some  abdominal  viscus.  Sometimes  the 
circumscribed  inflammation  is  protective  rather  than  calculated  to 
work  mischief.  It  arrests  a  destructive  perforation  of  the  membrane, 
or  it  limits  the  matter  discharged  to  a  certain  spot ;  it  may  at  least  do 
so  for  a  time,  for  general  peritonitis  is  very  apt  ultimately  to  follow. 

Partial  peritonitis  often  pursues  a  subacute  rather  than  an  acute 
course.  It  may  end  in  adhesions  or  lapse  into  a  chronic  state.  Its 
symptoms  are  much  the  same  as  those  of  a  more  general  inflamma- 
tion,— the  same  fever  and  constipation,  the  same  pain  and  tender- 
ness. The  fever  does  not,  however,  run  so  high,  and  the  pain  and 
the  great  tenderness  are  much  more  localized.  The  abdomen,  also, 
is  not  so  swollen  or  so  tympanitic.  But  perhaps  even  more  frequently 
than  in  general  peritonitis  are  found  accurately  limited  spots  of  dul- 
ness  on  percussion  corresponding  to  circumscribed  exudates  or  col- 
lections of  pus  in  the  peritoneal  cavity. 

Partial  peritonitis  is  more  liable  than  the  general  disease  to  be 
confounded  with  other  disorders.  Yet  error  can  hardly  arise  if  we 
bear  in  mind  that  it  is  precisely  with  the  morbid  states  of  the  viscera 
which  lie  below  the  peritoneum  that  the  circumscribed  inflammation 
of  the  serous  membrane  is  usually  connected,  and  that  local  peri- 
tonitis, therefore,  frequently  attends  the  very  disorders  from  which  we 
seek  to  distinguish  it.  Let  us,  however,  examine  into  some  of  the  com- 
plaints with  which  peritonitis,  whether  local  or  general,  may  be  con- 
founded. They  are — leaving  for  consideration  elsewhere  obstruction 
of  the  bowel,  appendicitis,  and  perityphlitis — 

Acute  Gastritis  ; 

Acute  Enteritis  ; 

Acute  Pancreatitis  ; 

Metritis  ; 

Cystitis  and  Distention  of  the  Bladder  ; 

Rheumatism  of  the  Abdominal  Walls  ; 

Abdominal  Hysteria  ; 

Colic. 

Acute  Gastritis. — Acute  inflammation  of  the  stomach  can  scarcely 
be  mistaken  for  inflammation  of  the  peritoneum,  provided  attention 

33 


526  MEDICAL  DIAGNOSIS. 

be  paid  to  the  history  of  the  case  and  to  the  seat  of  the  pain.  The 
former  disorder  begins  v\ath  vomiting,  and  tliis  continues  a  prominent 
symptom ;  whereas  vomiting  is  not  so  constant,  nor  does  it  occur  so 
early,  in  peritonitis.  The  pain  and  tenderness  are  hmited  to  the 
region  of  the  stomach  in  gastritis ;  they  are  diffused  in  peritonitis. 
They  may,  it  is  true,  be  localized  when  the  peritonitis  is  partial.  But 
acute  mflammation  of  the  gastric  peritoneum  is  hardly  encountered, 
save  as  an  attendant  on  severe  inflammation  of  the  stomach,  or  on 
destruction  of  its  coats, — the  form  of  gastritis  which  results  from 
irritant  poisons. 

Acute  Enteritis. — Enteritis  differs  from  general  peritonitis  by  the 
less  extended  tenderness  ;  by  the  seat  of  the  pain  near  the  umbilicus, 
and  its  more  paroxysmal  character ;  by  the  comparative  absence  of 
tympanites  and  abdominal  tumefaction;  and  by  the  greater  promi- 
nence of  nausea  and  vomiting.  Yet  it  cannot  be  distmguished  with 
certainty  from  the  partial  form  of  acute  peritonitis,  to  which,  in  truth, 
some  of  its  symptoms  are  clearly  o^\ing. 

Acute  Pancreatitis. — This  is  a  cause  of  peritonitis  easily  over- 
looked. The  pancreatic  inflammation  mostly  arises  in  consequence 
of  the  extension  of  a  gastro-duodenal  inflammation  along  the  pan- 
creatic duct ;  or  it  may  follow  hemorrhage  into  the  pancreas.  In  the 
former  case  we  find  sudden  pain,  deep-seated,  constant  or  paroxys- 
mal ;  tenderness  ;  and  tympany  in  the  epigastrium  in  the  region  of 
the  pancreas,  with  nausea  and  vomiting.  This  is  gradually  followed 
by  peritonitis  at  the  same  place,  and  by  a  low  fever.  Constipation 
is  frequent,  and,  with  the  other  symptoms,  has  led  to  the  diagnosis 
of  acute  uitestinal  obstruction  and  to  laparotomy.  The  symptoms 
of  acute  panrceatitis  may  be  also  produced  by  extensive  fat  necrosis 
of  the  pancreas.  In  hemorrhagic  pancreatitis  the  malady  runs  a  rapid 
course.  The  disease  occurs  in  persons  over  thirty  years  of  age.  The 
attack  begins  with  violent  pain  in  the  upper  part  of  the  abdomen ; 
nausea,  vomiting,  and  abdominal  swelling  soon  follow,  and  delirium 
and  signs  of  collapse  appear.  There  is  usually  constipation.  The 
temperature,  as  we  know  from  Fitz's^  comprehensive  study,  may 
remain  normal.  The  disease  is  most  likely  to  be  confounded  with 
acute  perforative  peritonitis.  It  usually  proves  fatal  in  from  two  to 
four  days.  The  hemorrhage  may  lead  to  gangrene  ;  in  either  case 
the  signs  of  peritonitis  ■  are  marked.  Hemorrhage  may  occasion 
sudden  death.^     Suppurative  pancreatitis  has  much  the  same  symp- 


1  Middleton-Goldsmith  Lecture  for  1889. 

^  Draper,  Transactions  of  the  Association  of  American  Physicians,  1886. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       527 

toms ;  but  it  does  not  run  so  acute  a  course, — is,  indeed,  often 
chronic  ;  there  is  apt  to  be  irregular  fever.  In  a  case  that  I  saw  with 
Dr.  Hulshizer,  the  pain  was  severe  but  paroxysmal,  repeated  chills 
occurred,  there  was  sugar  in  the  urine,  and  decided  polynuclear 
leucocytosis.^ 

Iletritis. — In  this  the  pain  on  pressure  is  confined  to  the  uterus 
and  its  annexes,  and  there  is  little  or  no  tympanites.  In  puerperal 
peritonitis  with  metritis,  the  signs  of  inflammation  of  the  serous 
membrane  mask  those  of  inflammation  of  the  womb. 

Cystitis  and  Distention  of  the  Bladder. — Both  inflammation  and 
distention  of  the  bladder  are  occasionally  mistaken  for  general  acute 
peritonitis.  An  acute  inflammation  of  the  bladder  gives  rise  to  fre- 
quent calls  to  pass  urine:  yet  the  act  is  performed  with  great  diffi- 
culty, and  in  severe  cases  may  become  impossDole  ;  the  bladder  dis- 
tends ;  a  sense  of  uneasiness  is  felt  in  the  perineum  ;  the  region  above 
the  pubes  becomes  tender,  and  sounds  dull  on  percussion ;  there  is 
great  restlessness,  fever ;  at  times  vomiting  and  hiccough  supervene. 
Such  cases  resemble  those  of  peritonitis  with  suppression  of  the  uri- 
nary discharge  and  with  strangury.  But  the  urine  voided  in  perito- 
nitis is  simply  high-colored,  like  that  of  any  febrile  state.  In  cystitis 
it  contains  large  quantities  of  mucus  and  pus,  and  often  blood  and 
crystals  of  phosphates.  Again,  the  abdominal  tenderness  is  localized, 
and  is  frequently  accompanied  by  a  smarting  in  the  course  of  the 
urethra.  Neither  of  these  signs  is  encountered  in  peritoneal  inflam- 
mation, and,  as  a  rule,  the  temperature  in  this  is  higher.  The  urinary 
disturbance  which  not  infrequently  takes  place  in  the  latter  dis- 
order is  attributable  to  inflammation  of  the  peritoneum  covering  the 
bladder. 

An  over-distention  of  the  bladder,  not  the  result  of  inflammation 
of  its  coats,  may  produce  a  local  tenderness  spread  over  a  consider- 
able portion  of  the  lower  part  of  the  abdomen.  But  the  outhne  of 
the  dulness,  which  is  the  same  as  that  of  the  tenderness,  the  fact  that 
the  patient  has  generally  not  passed  urine  in  any  quantity  for  a  con- 
siderable time,  the  almost  normal  temperature,  and  the  sudden  cessa- 
tion of  the  supposed  peritonitis  on  passing  a  catheter,  show  the  true 
nature  of  the  malady.^ 

Inflammation  and  Abscess  in  the  Abdominal  Muscles. — When  the 
abdominal  walls  become  inflamed,  symptoms  are  occasioned  that  are 

^  Philadelphia  Medical  Journal,  June  11,  1898.  . 

2  A  case  of  this  kind,  occurring  after  delivery,  is  given  by  Lever,  Guy's  Hospital 
Reports,  2d  Series,  vol.  viii.  p.  41. 


528  MEDICAL  DIAGNOSIS. 

* 

not  always  easily  distinguished  from  those  of  acute  peritonitis.  The 
disease  is  attended  with  some  fever,  with  pain  increased  by  move- 
ment, by  the  act  of  coughing,  and  by  pressure,  and  sometimes  with 
excessive  tenderness.  The  seat  of  the  inflammation  is  generally  the 
rectus  muscle  and  the  surrounding  cellular  tissue.  The  parts  on  one 
side  of  the  umbilicus  are  commonly  attacked,  and  it  is  there  that  a 
hard  swelling  is  perceived,  over  which  the  skin  is  rather  hot  and 
sometimes  red.  The  tumefaction  gradually  disappears  by  resolution, 
or  else  fluctuation  becomes  from  day  to  day  more  distinct,  showing 
that  suppuration  is  taking  place  ;  and  the  pus  being  discharged,  imme- 
diate relief  follows,  and  the  pain  and  febrile  symptoms  cease. 

Now,  the  disease  rarely  runs  a  very  acute  course ;  it  lasts  at  least 
a  week  or  two,  and  often  much  longer.  Where  much  of  the  muscle 
is  involved,  the  complaint  simulates  peritonitis, — more,  however,  the 
partial  than  the  general  kind.  Where  the  inflammation  of  the  mus- 
cle is  not  extended,  the  resemblance  to  inflammatory  affections  of  the 
organs  lying  underneath  the  point  of  tenderness  is  even  greater  than 
to  inflammation  of  the  peritoneum.  Hepatitis,  splenitis,  and  gastritis 
have  been  mistaken  for  the  affection  of  the  abdominal  parietes.  These 
errors  can  be  avoided  only  by  taking  into  account  the  absence  of  dis- 
turbed function  of  the  suspected  viscus  ;  often,  too,  the  peculiar  swell- 
ing furnishes  a  clue  to  the  real  nature  of  the  case.  But  as  regards 
signs  of  disturbed  function,  we  must  bear  in  mind  that  these  are  pro- 
duced occasionally  by  disorder  of  the  adjoining  viscera.  Thus,  we 
have  jaundice  in  abscesses  seated  in  the  walls  in  the  right  hypochon- 
drium.^  Abscesses  in  the  abdominal  wahs  are  sometimes  sympto- 
matic of  a  more  distant  lesion,  as  of  caries  of  a  rib.^ 

Can  we  distinguish,  with  anything  like  certainty,  between  abscesses 
in  the  abdominal  walls  and  instances  of  partial  peritonitis  leading  to 
collections  of  pus  in  the  peritoneal  cavity  f  I  believe  not ;  for  in  both 
there  is  a  tumefaction ;  in  both  the  general  symptoms  are  much  the 
same  ;  and,  as  happens  sometimes  in  peritoneal  abscesses,  the  pus 
presses  its  way  through  the  parietes  of  the  abdomen.  Yet  whenever 
we  find  a  swelling  which  has  come  on  gradually,  or  has  followed  a 
blow  or  a  kick  on  the  abdomen,  or  a  swelling  which  is  very  hard 
before  fluctuation  appears ;  whenever  the  softening  of  the  tumor  is 
immediately  preceded  by  distinct  chills,  and  the  skin  covering  it  is 
tense,  and  heated,  or  reddish  ;  wherever  there  are  no  symptoms  point- 
ing to  a  partial  peritonitis,  as  an  attendant  on  visceral  disease,  or  as  a 

1  As  mentioned  by  Habershon,  Diseases  of  the  Abdomen,  1878. 
^  Oppolzer,  Wiener  Medizinische  Wochenschrift,  1862. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       529 

* 
consequence  of  general  peritonitis, — we  may  infer  that  the  affection 

lies  in  the  abdominal  walls.  But  the  skin  is  not  always  discolored 
or  hot,  and  the  beginning  of  the  swelling  is  sometimes  veiled  in  ob- 
scurity. In  some  instances  I  have  seen,  in  which  there  was  great 
doubt,  the  aspirator  drew  off  a  very  offensive  pus  and  broken-down 
material ;  and  I  looked  upon  this — as  the  sequence  proved,  correctly 
— as  indicating  abscess  in  the  abdominal  walls.  Abscesses  within  the 
abdomen  seated  at  the  upper  part,  if  not  caused  by  abscess  of  the 
liver,  are,  as  Bristowe  points  out,^  largely  due  to  perforation  of  one  of 
the  hollow  viscera  with  circumscribed  peritoneal  suppuration. 

But  it  is  not  every  case  of  abscess  in  the  walls  which  is  attended 
with  symptoms  that  render  it  likely  to  be  mistaken  for  the  results  of 
inflammation.  Sometimes  the  preceding  tumefaction  is  so  hard,  or  it 
is  so  long  before  the  process  of  suppuration  sets  in,  that  the  affection 
is  more  liable  to  be  confounded  with  abdominal  tumors.  The  most 
trustworthy  points  of  difference  are  furnished  by  a  study  of  the  his- 
tory of  the  case ;  by  the  slow  growth  of  the  tumor  on  the  one  hand, 
and  its  far  more  rapid  growth  on  the  other  ;  by  the  rise  in  temperature 
and  by  the  absence,  or  at  all  events  the  comparative  absence,  of  signs 
denoting  serious  disturbance  in  one  or  several  of  the  abdominal 
viscera.  Then,  in  doubtful  cases,  the  aspirator  or  the  exploring 
needle  will  be  of  use.  The  fluid  thus  obtained  shows,  under  the 
microscope,  shreds  of  broken-down  muscle  and  of  areolar  tissue, 
mixed,  if  suppuration  have  begun,  with  pus.  Again,  stress  may  be 
laid  on  the  occurrence  of  chills  preceding  the  softening  of  the  mass. 
In  some  patients  the  inflammation  is  unaccompanied  by  any  appre- 
ciable signs  ;  it  leads  to  gradual  changes  in  the  muscular  fibres,  which 
do  not  reveal  themselves  until  the  disorganized  muscle  gives  way. 
The  fibres  undergo  softening  or  a  true  fatty  metamorphosis,  and  the 
slightest  force  suffices  to  produce  a  rupture.  Not  a  few  cases  have 
been  reported  in  which  one  of  the  recti  muscles  has  been  torn  asunder 
during  a  fit  of  coughing.  The  seat  of  laceration  is  generally  about 
midway  between  the  umbilicus  and  the  pubes,  a  little  to  one  side  of 
the  median  line  ;  the  rent  fills  with  blood,  occasioning  a  circumscribed 
swelling  and  rigidity  of  the  abdomen.  There  is  sometimes  pain,  with 
nausea,  vomiting,  and  obstinate  constipation.  Nay,  the  symptoms 
have  imitated  so  closely  a  strangulated  ventral  hernia  as  to  have  led 
to  the  performance  of  an  operation,^ 

1  Lancet,  Sept.  1883, 

^  Richardson's  case,  American  Journal  of  the  Medical  Sciences,  Jan,  1857. 
Further  instances  of  this  accident  are  given  by  Virchow,  in  the  Wiirzburg.  Ver- 
handl.,  Band  vii.     The  description  of  abscesses  in  the  abdominal  parietes  I  have 


530  MEDICAL  DIAGNOSIS. 

Rheumatism  of  the  Abdominal  Walls. — Occasionally  rheumatism 
attacks  the  abdominal  muscles,  and  gives  rise  to  local  signs  similar 
to  those  of  peritonitis.  But  the  pain  is  not  so  constant,  nor  is  it 
spontaneous,  as  in  this  disorder.  It  is  also  less  affected  by  move- 
ments or  by  pressure.  Deep  pressure  causes  little  or  no  more  pain 
than  slight  pressure  ;  and  it  is  only  when  the  muscles  are  placed  on 
the  stretch  that  the  pain  is  severe,  or  sometimes,  indeed,  at  all  pro- 
duced. The  pain  is  often  one-sided,  or  much  more  marked  on  one 
side,  and  v^e  find  no  meteorism,  and  but  slightly  elevated  tempera- 
ture, and  not  the  anxious  countenance  of  peritonitis.  Moreover,  the 
attack  is  apt  to  happen  in  those  of  rheumatic  tendencies,  and  there  is 
concentrated,  highly  acid,  scalding  urine.  Rheumatic  peritonitis  may 
supervene  on  rheumatism  of  the  abdominal  wall. 

Abdominal  Hysteria. — No  disease  simulates  peritonitis  more  closely 
than  hysteria.  The  abdomen  may  be  extremely  painful  to  the  touch, 
swollen  and  distended  with  gas,  fever  may  set  in  temporarily,  and  yet 
the  whole  disorder  be  purely  hysterical.     To  illustrate  : 

An  unmarried  woman,  twenty  years  of  age,  consulted  me  on  ac- 
count of  extreme  tenderness  of  the  abdomen  which  had  developed 
in  a  few  days.  The  abdomen  was  swollen  and  tympanitic,  and  so 
sensitive  that  it  would  not  bear  the  pressure  of  her  clothes  ;  the  pulse 
was  frequent ;  the  skin  dry ;  the  tongue  lightly  coated ;  the  bowels 
constipated ;  the  countenance  expressive  of  distress.  Here  was  cer- 
tainly a  group  of  symptoms  like  those  of  acute  peritonitis.  But  the 
absence  of  the  wiry  pulse,  the  comparatively  slight  fever, — slighter, 
certainly,  than  was  to  be  expected  from  such  general  and  great  ten- 
derness,— and  the  expression  of  countenance,  arrested  my  attention. 
I  found  that  the  patient  had  had  similar  attacks  previously  ;  that  they 
had  come  on  sometimes  shortly  before,  sometimes  shortly  after,  her 
menstrual  period ;  but  that  for  several  months  her  menses  had  ceased 
to  flow.  The  abdominal  tenderness  was  in  reality,  as  she  represented 
it  to  be,  very  great ;  yet  strong  pressure  produced  no  more  pain  than 
the  lightest  touch.  Nor  was  the  pain  increased  by  deep  inspiration, 
or  by  coughing,  or  by  extending  the  thighs.  Taking  all  these  circum- 
stances into  account,  as  well  as  her  age  and  sex,  and  her  nervous 
temperament,  instead  of  treating  her  for  acute  peritonitis,  cold-water 
injections,  mild  purgatives,  and  a  mixture  of  assafcetida  and  valerian 
were  employed.  Under  these  remedies,  all  the  symptoms  of  the 
apparent  peritonitis  speedily  vanished. 

drawn  from  cases  chiefly  coming  under  my  own  notice,  and  from  manuscript  notes 
taken  by  Dr.  J.  K.  Kane  at  the  Philadelphia  Hospital. 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       531 

Yet  all  cases  of  abdominal  hysteria  do  not  pass  off  so  quickly ; 
sometimes  they  are  much  more  persistent,  or  recur  frequently.  They 
are  from  the  onset  unattended  with  fever,  or,  as  the  thermometer 
shows,  the  fever  is  fitful  and  soon  ceases.  The  absence  of  febrile 
excitement,  too,  especially  if  taken  in  connection  with  the  several 
localized  and  more  or  less  distinctly  circumscribed  spots  of  tenderness, 
enables  us  to  distinguish  between  peritonitis  and  those  instances  of 
neuralgia  of  nerves  supplying  the  abdominal  parietes,  to  which  women 
who  are  laboring  under  disorders  of  the  uterus  aje  so  liable. 

Colic. — As  already  stated,  the  pain  of  colic  is  paroxysmal,  and  not 
attended  with  fever,  or  with  much,  if  any,  tenderness  ;  while  the  pain 
of  an  inflamed  peritoneum  is  constant,  and  associated  with  the  greatest 
tenderness  and  with  fever.  Cases  of  cohc  do  indeed  occur  in  which 
we  find  fever  and  some  tenderness  ;  but  it  is  likely  that  in  such  cases 
the  peritoneum  is  really  in  parts  injected  or  slightly  inflamed. 

The  same  remarks  are  applicable  to  those  severe  paroxysmal  pains 
which  accompany  the  passage  of  gall-stones  or  of  urinary  concretions, 
or  which  occur  at  the  menstrual  periods.  They  are  frequently  spoken 
of  as  varieties  of  colic,  and,  as  far  as  their  discrimination  from  perito- 
nitis goes,  there  is  no  difference, — it  rests  on  the  same  grounds  pre- 
cisely ;  for  when  there  is  fever  or  tenderness  on  pressure,  it  is  likely 
that  inflammation  has  been  set  up  in  those  parts  in  which,  or  in  the 
neighborhood  of  which,  the  pain  is  felt.  In  the  so-called  uterine  colic, 
an  injection  of  the  peritoneum  has  positively  been  demonstrated. 

Chronic  Peritonitis. — An  acute  attack  of  peritonitis  may  imper- 
ceptibly assume  a  chronic  form.  The  fever  gradually  disappears,  or 
at  all  events  lessens ;  but  the  exudations  into  the  peritoneal  cavity, 
whether  organized  or  not,  remain,  and  so  do  some  abdominal  pain 
and  tenderness.  In  this  condition  the  patient  may  continue  for  many 
months,  now  and  then  a  fresh  inflammation  starting  up  in  the  peri- 
toneum and  giving  rise  to  acute  symptoms,  or  an  intercurrent  severe 
diarrhoea  leading  to  rapid  loss  of  strength.  Again,  the  disease  may 
develop  slowly,  be  latent  from  the  onset,  and  may  not  attract  atten- 
tion until  the  abdomen  swells.  In  all  cases,  no  matter  what  their 
origin,  if  they  last  for  any  length  of  time,  debility  and  emaciation  be- 
come marked  symptoms  ;  hectic  fever  is  observed ;  decided  effusion 
in  the  peritoneum  is  generally  noticed  ;  the  legs  become  oedematous ; 
and  the  patient  may  present  the  symptoms  of  septic  poisoning  and 
die  worn  out.  Where  recovery  takes  place,  the  exudation  into  the 
peritoneal  cavity  is  either  discharged  through  adjacent  viscera ;  or 
is  gradually  absorbed ;  or  is  transformed  into  tissue.  When  the 
disease  terminates  in  this  way,  it  is  apt  to  leave  its  traces  in  a  chronic 


532  MEDICAL   DIAGNOSIS. 

thickening  and  roughening  of  the  peritoneum.  A  friction  may  be 
often  felt.  Chronic  peritonitis  of  latent  origin  and  leading  to  much 
thickening  is  sometimes  found  to  attend  cirrhosis  of  the  liver  or  con- 
tracted kidney.  Under  no  circumstances  is  chronic  peritonitis  likely 
to  be  an  independent  affection. 

Chronic  peritonitis  may  be  confounded  with  affections  of  the  liver 
attended  by  impediment  in  the  portal  circle ;  and  what  adds  to  the 
difficulty  in  diagnosis  is,  that  the  liver  is  apt  to  atrophy  in  chronic 
diffuse  peritoneal  inl^ammation.  The  greater  and  more  diffuse  ten- 
derness, the  evening  exacerbations  of  temperature,  the  absence  of 
marked  dilatation  of  the  abdominal  veins,  and  the  less  extensive  peri- 
toneal effusion  indicate  the  latter  affection. 

Chronic  peritonitis  is  often  found  in  connection  with  tubercles  or 
with  cancer.  It  then  gives  rise  to  very  considerable  abdominal  en- 
largement, and  it  is  with  the  diagnosis  of  abdominal  enlargements 
that  these  forms  of  chronic  peritonitis  will  be  considered. 

Diseases  attended  with  Pain  and  Tenderness  in  the  Right 

Ihac  Fossa. 

Appendicitis. — Inflammation  of  the  appendix  is  pre-eminently 
the  disease  attended  with  pain  and  tenderness  in  the  right  iliac  fossa. 
The  appendix  has  an  average  length  of  four  inches,  and  the  diameter 
of  a  goose-quill.  It  lies  in  the  right  iliac  fossa,  but  is  variable  in 
position.  It  points  for  the  most  part  downward,  or  downward  and 
inward.  A.  T.  Bristow  and  Fowler^  locate  for  it  a  central  point  by 
drawing  a  line  from  the  anterior  superior  spinous  process  of  the  ilium 
to  the  median  line,  and  placing  the  central  point  from  two  to  two  and 
a  half  inches  within  the  anterior  superior  spinous  process.  From 
this  central  point  the  appendix  will  radiate  in  different  directions. 
The  usual  location  of  the  appendix  is  at  the  edge  of  the  right  rectus 
muscle  below  a  line  drawn  from  the  centre  of  the  umbilicus  to  the 
anterior  superior  spinous  process.  Appendicitis  is  essentially  a  dis- 
ease of  adolescence  and  of  young  adults.  It  presents  itself  clinically 
in  these  forms  :  acute  catarrhal  appendicitis  ;  ulcerative  and  suppura- 
tive appendicitis  ;  perforative  appendicitis  ;  chronic  recurring  appen- 
dicitis. 

Acute  catarrhal  appendicitis  may  come  on  from  exposure  to  cold 
and  wet.  Fowler  cites  two  such  cases.  Much  more  generally  it  is  an 
infectious  process  due  to  hardened  fecal  masses  leading  by  the  irrita- 
tion they  produce  to  exudations  in  which  extraordinary  development 

^  Appendicitis,  Philadelphia,  1894. 


DISEASES  OF  THE   INTESTINES  AND  PEEITONEUM.       533 

of  bacteria,  as  of  the  bacterium  coli  commune,  takes  place.  It  may 
also  be  caused  by  other  infecting  processes  or  micro-organisms.  The 
far  greater  prevalence  of  appendicitis  since  the  recent  wide-spread 
epidemics  of  influenza  suggests  that  this  subtle  poison,  too,  may  act  as 
an  exciting  cause.  The  disease  may  also  result  from  vascular  disturb- 
ances or  torsion  of  the  part.  It  is  at  the  bedside  always  extremely 
difficult  to  say  what  cause  has  given  rise  to  the  attack. 

Whatever  the  immediate  cause,  whether  it  be  a  quickly  acting  one, 
or,  as  is  more  common,  have  been  silently  working,  the  attack  itself 
is  generally  sudden,  and  announces  itself  by  acute  abdominal  pain, 
by  tenderness  in  the  right  iliac  fossa,  by  nausea  and  vomitmg.  The 
pain  and  the  tenderness  are  very  significant.  The  pain  may  be 
referred  to  the  lower  part  of  the  abdomen,  but  it  is  very  often 
referred  to  the  umbilicus  or  to  the  epigastrium.  It  has,  especially 
at  first,  the  character  of  colic.  It  is  soon  noted  to  be  associated 
with  tenderness,  which  is  chiefly  manifest  at  or  near  McBurney's 
point.  This  corresponds  to  the  outer  edge  of  the  right  rectus  muscle, 
and  is  most  readily  located  by  fixing  a  spot  midway  between  the  ante- 
rior superior  spine  of  the  right  ilium  and  the  umbihcus.  The  patient 
hes  on  his  back,  because  to  do  otherwise  increases  the  pain,  and  very 
often  the  right  rectus  muscle  is  somewhat  tense,  a  fulness  or  a  slight 
tumefaction  can  be  perceived  in  the  right  iliac  fossa,  and  there  is  some 
impairment  of  tympanitic  resonance  on  percussion.  Tenderness  and 
swelling,  as  well  as  the  shape  of  the  appendix,  may  at  times  be  recog- 
nized by  deep  pressure,  and  palpation  of  the  appendix,  as  recom- 
mended by  Edebohls,^  may  thus  become  of  value.  In  some  instances, 
and  I  have  met  with  a  number  of  them,  the  sensitiveness  is  not  in  the 
right  but  in  the  left  iliac  fossa.  Again,  the  tenderness  may  be  at  the 
upper  part  of  the  appendix,  below,  but  near,  the  gall-bladder.  Ten- 
derness is  always  a  very  important  sign,  and  when  it  lessens  both  in 
degree  and  in  extent  it  denotes  decreasing  inflammation.  The  nausea 
and  vomiting  disappear  in  the  progress  of  the  case,  though  vomiting 
may  return  should  there  be  perforation.  If  the  peritonitis  become 
general,  abdominal  distention  will  be  marked.  Other  symptoms  met 
with  in  appendicitis  are  moderate  fever,  constipation,  urine  diminished 
and  frequently  containing  albumin  and  indican. 

Some  cases  do  not  begin  so  acutely,  but  are  rather  subacute.  The 
complaint  presents  the  following  history  and  symptoms  :  The  patient 
has  been  suffering  for  some  time  from  constipation,  or  alternately  from 
diarrhoea  and  constipation.     He  has  a  dull  pain  referred  principally 

'  American  Journal  of  the  Medical  Sciences,  May,  1894. 


534  MEDICAL  DIAGNOSIS. 

to  the  iliac  fossa,  and  radiating  to  tlie  hips.  When  tlie  iliac  region  is 
examined,  it  is  tender  to  the  touch,  full  and  hard,  and  dull  on  per- 
cussion, while  around  the  dulness  there  is  a  very  tympanitic  sound, 
if  the  intestine  be  much  distended.  Colicky  pains  occur  from  time  to 
time,  but  are  mainly  confined  to  the  lower  portion  of  the  abdomen. 

No  matter  what  the  beginning,  the  case  in  its  further  progress 
exhibits  varied  features :  it  may  end  in  resolution,  and  hardened 
fecal  matter  is  often  passed ;  or  the  tenderness  in  the  iliac  fossa  may 
become  greater,  and  vomiting,  decided  fever,  and  the  marked  signs  of 
an  extending  peritonitis  appear ;  or  ulceration  of  the  appendix  may 
allow  a  discharge  of  extraneous  matter  into  the  peritoneal  cavity, 
which  produces  violent  general  peritonitis,  or  an  abscess  forms  that 
ruptures  and  perhaps  leads  to  the  same  results  ;  or,  again,  the  bowel 
may  become  so  paralyzed  or  so  constricted  that  it  can  no  longer  pro- 
pel its  contents,  and  the  patient  dies  with  all  the  distressing  signs  of 
intestinal  obstruction. 

There  are  other  terminations  with  which  experience  makes  us 
familiar.  The  attack  may  end  in  a  chronic  appendicitis,  indicated 
by  persistent  tenderness  and  some  swelling,  pain  on  walking,  and 
often  dyspeptic  symptoms  and  depression  of  spirits  ;  or  the  chronic 
inflammation  may  lead  to  a  series  of  recurring  acute  attacks.  Then 
as  complications  in  appendicitis  we  may  have  thrombosis  of  the  iliac 
vein,  iliac  phlebitis,  post-ceecal  abscess,  fistula  into  the  bladder  or 
rectum,  hepatic  abscess. 

There  are  two  very  important  questions  that  always  arise  in 
appendicitis  :  Is  there  pus  present  ?     Has  perforation  occurred  ? 

It  is  always  difficult  to  determine  the  presence  of  pus,  and  there 
are  no  certain  signs.  Chills  are  generally  absent ;  the  temperature  is 
of  little  value.  The  most  trustworthy  signs  are  very  decided  tender- 
ness, a  local  swelling,  marked  rigidity  of  the  right  rectus  muscle,  and 
waves  of  pain  in  the  affected  region. 

Perforation  of  the  appendix  is  most  often  seen  among  healthy  young 
men.  It  is  found  chiefly  in  the  form  of  appendicitis  that  has  been 
caused  by  seeds  and  concretions  of  various  kinds,  cherry-stones,  and 
foreign  bodies.  In  a  certain  proportion  of  cases  the  symptoms  have 
been  latent  until  the  perforation  happened.  Its  most  constant  and  the 
first  decided  symptom  is  sudden,  severe  abdominal  pain.  This  oc- 
curred in  eighty-four  per  cent,  of  the  cases  which  Fitz  in  his  admirable 
essay  has  analyzed,^  The  pain  is  mostly  at  first  in  the  right  iliac  fossa, 
and  is  followed  by  tenderness  which  gradually  extends.     It  may  be 

1  Transactions  of  the  Association  of  American  Physicians,  1886. 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       535 

accompanied  by  a  chill,  but  I  have  known  pain  absent  where  a  chill 
was  decided.  Fever,  with  a  temperature  of  between  100°  and  102°, 
is  next  observed ;  but  it  is  not  constant,  for  I  have  met  with  a  temper- 
ature nearly  normal  in  a  case  in  which  a  gangrenous  perforation  of 
the  appendix  was  found.^  A  circumscribed  resisting  swelling  in  the 
right  iliac  fossa,  which  forms  in  from  two  to  five  days,  with  impaired 
resonance  on  percussion  and  with  a  sense  of  fluctuation  from  the 
abscess  that  develops,  and  disturbed  micturition,  establish  the  diag- 
nosis. A  rectal  examination  may  aid  us  in  detecting  the  tumor,  but, 
as  I  know  from  experience,  is  not  absolutely  to  be  depended  on  as  a 
means  of  recognizing  the  swelling  or  the  pus  that  has  formed.  In 
the  majority  of  cases  general  peritonitis  begins  from  the  second  to 
the  fourth  day  after  the  perforation.  The  cases  that  die  from  shock 
die  before  the  second  day ;  but,  as  a  rule,  the  collapse  comes  on  more 
slowly  than  in  other  forms  of  perforative  peritonitis.  Leucocytosis, 
Richardson  tells  us,  is  invariable  in  perforative  appendicitis.  Obliter- 
ation of  the  dulness  over  the  liver  and  spleen  is  not  as  often  found 
as  in  other  forms  of  intestinal  perforation. 

A  question  that  arises  is  whether  we  can  distinguish*  inflammation 
of  the  appendix  from  an  inflammation  of  the  ccecum,  both  of  which 
were  formerly  included  under  the  name  typhlitis.  There  is  no  cer- 
tainty in  the  diagnosis.  But  these  facts  will  often  aid  us  greatly. 
Most  of  the  cases  of  inflammation  of  the  caecum  are  due  to  impacted 
faeces,  and  the  history  of  preceding  long-continued  constipation,  a  re- 
sisting elongated  mass  in  the  right  groin,  slight  pain,  and  absence  of 
fever,  are  very  significant.  Then,  perforating  inflammation  of  the 
caecum  is  very  rare,  while  perforation  of  the  appendix  is  of  frequent 
occurrence. 

Much  used  to  be  said  about  inflammation  of  the  loose  areolar 
tissue  around  the  caecum,  jjerityjMitis,  and  consequent  abscess.  But 
we  now  know  that  the  abscess  nearly  always  has  its  origin  in  disease 
of  the  appendix.  The  collection  of  pus  may  find  its  way  into  neigh- 
boring viscera,  or  be  discharged  externally,  or  become  encysted,  or 
the  sac  rupture  and  fatal  peritonitis  ensue.  The  tumefaction  which 
the  abscess  occasions  is  generally  very  evident.  When,  however,  the 
pus  burrows  under  the  iliac  fascia,  the  swelling  may  be  slight.  But 
under  such  circumstances  there  appears  a  characteristic  sign :  the 
pain  on  moving  the  right  foot  is  intense,  because  the  iliac  muscles 
become  involved  in  the  disorder.  If  the  swelling  be  great,  there  may 
be  oedema  of  the  foot  and  numbness  of  the  thigh,  from  the  pressure 

^  Seen  with  Dr.  Morton. 


536  MEDICAL   DIAG^^OSIS. 

on  the  vein  and  nerves.  Perityphlitis  with  marked  swelhng  in  the 
right  iliac  fossa  may  disappear  without  an  abscess  forming. 

Chiefly  on  account  of  the  pain  and  tenderness,  acute  appendicitis 
may  be  confounded  with  a  number  of  diseases,  prominent  among 
which  are  colic ;  bilious  colic ;  renal  colic ;  acute  cholecystitis ;  per- 
foration of  the  gall-bladder :  typhoid  fever ;  ulceration  of  the  lower 
part  of  the  ileum  :  obstruction  of  the  bowel ;  tumors  of  the  kidney 
and  abscesses  in  or  around  it ;  floating  kidney ;  inflammation  of  the 
right  ovary ;  extrauterine  pregnancy :  pelvic  heematocele  ;  pehdc  peri- 
tonitis ;  tubercular  peritonitis  ;  abscess  in  the  abdominal  walls  ;  psoas 
abscess ;  hip-joint  chsease ;  abscess  of  the  liver ;  distention  of  the 
caecum  ;  cancer  of  the  caecum  ;  pneumonia. 

The  sudden  jDain,  the  acute  indigestion,  the  nausea  and  vomiting 
may  cause  appendicitis  at  its  beginning  to  be  mistaken  for  eolic,  espe- 
cially for  bilious  colic,  but  the  localization  of  the  pain  and  particularly 
the  tenderness  in  the  right  iliac  fossa  are  very  different.  On  the  other 
hand,  the  jaundice  that  attends  or  follows  bilious  colic  is  not  a  symp- 
tom of  appendicitis,  and  the  pain  of  this  does  not  racUate  to  the  shoul- 
der and  the  scapula.  The  same  localization  of  the  tenderness  is  of 
value  in  distinguishing  renal  colic,  where  the  tenderness,  if  it  exist  at 
all,  is  most  marked  over  Poupart's  ligament.  Moreover,  rectal  and 
vesical  tenesmus  and  retraction  of  the  testicle,  common  in  renal  colic, 
are  very  rare  in  appendicitis.  Yet  there  are  cases  of  appendicitis  at 
its  upper  end  that  are  very  misleadmg,  and,  as  in  two  cases  I  saw, 
one  with  Dr.  Keen,  the  other  with  Dr.  Dupont  Smith,  only  to  be 
recognized  by  the  changing  seat  of  the  pain.  In  Dupont  Smith's  case 
tympany  was  a  marked  symptom. 

Pain  and  tenderness  in  the  right  iliac  fossa  may  be  the  cause  of 
typhoid  fever  being  confounded  with  appendicitis.  But  neither  pain 
nor  tenderness  is  great  in  typhoid  fever ;  then  the  characteristic  tem- 
perature record,  the  nervous  symptoms,  the  diarrhoea,  the  eruption, 
furnish  striking  points  of  difference.  Appendicitis  may  exist  as  a 
complication  of  typhoid  fever,  as  we  shall  find  while  treating  of 
typhoid  fever. 

Ulceration  of  the  lower  part  of  the  ileum  produces  pain  and  ten- 
derness in  the  iliac  fossa.  But,  combined  as  the  ulceration  generally 
is  with  tubercular  disease,  the  history  of  the  case  gives  a  clue  to  the 
nature  of  the  malady.  Moreover,  diarrhoea  occurs,  and  there  is  not 
present  a  tumefaction  dull  on  percussion.  Should,  however,  perfora- 
tion of  the  bowel  take  place  before  the  patient  is  seen,  and  general 
peritonitis  come  on,  the  diagnosis  is  not  so  readily  made,  because  we 
are  deprived  of  the  decisive  proof  furnished  by  the  swelling. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       537 

Another  difficult  diagnosis  is  at  times  that  regarding  obstruction 
of  the  bowel ;  the  more  difficult  because  appendicitis  may  become 
a  cause  of  intestinal  obstruction.  In  both  there  is  pain  ;  in  both 
constipation  ;  in  both  vomiting.  But  the  pain  in  obstruction  is  not 
localized,  or  attended  with  such  a  significant  seat  of  tenderness  as 
McBurney's  point ;  the  constipation  in  appendicitis  is  not  so  absolute, 
and  flatus  passes  ;  the  vomiting  in  this  disease  occurs  early,  then  gen-' 
erally  stops ;  late  vomiting  is  the  rule  in  obstruction,  and  it  becomes 
fecal.  Though  fever  is  not  a  marked  symptom  of  appendicitis,  there 
is  generally  some.  Acute  intussuscejjtion  has  a  different  history,  and 
makes  its  appearance  suddenly  with  such  peculiar  signs  that,  although 
it  may  likewise  occasion  a  tumor  in  the  right  iliac  region,  it  can  be 
generally  distinguished  from  appendicitis.  Yet,  where  the  latter  leads 
to  intestinal  obstruction,  the  diagnosis  is  not  always  obvious ;  and 
tenesmus  and  discharge  of  bloody  mucus  from  the  rectum  may  also 
happen  in  appendicitis  as  well  as  in  intussusception.  Moreover,  both 
are  diseases  to  which  the  young  are  specially  liable. 

As  regards  tumors  of  the  kidney  and  abscesses  in  it  or  around  it,  the 
situation  of  the  swelling  is  not  exactly  in  the  ileo-csecal  region,  or  at 
all  events  it  is  not  confined  to  this  region.  The  mass  of  the  tumor 
lies  in  the  loin,  or  above  the  anterior  termination  of  the  crest  of  the 
ileum ;  and  the  urine  contains  ingredients,  such  as  pus,  or  blood,  or 
heavy  deposits  of  urates  or  phosphates,  which  show  that  the  secretion 
of  the  kidney  is  abnormal.  Moreover,  there  is  no  intestinal  disturb- 
ance or  marked  local  tenderness,  such  as  we  find  in  appendicitis.  In 
floating  kidney  the  mobility  of  the  displaced  organ,  the  slight  tender- 
ness, the  dyspeptic  symptoms,  and  the  throbbing  of  the  abdominal 
aorta  are  very  significant.  The  occurrence  of  attacks  of  severe  ab- 
dominal pain,  with  vomiting  and  fever,  may  be  misleading,  but  their 
frequent  recurrence  and  the  absence  of  localized  swelling  over  the 
seat  of  the  appendix  are  valuable  signs. 

An  inflammation  of  the  right  ovary  gives  rise  to  pain  and  tenderness 
in  the  right  iliac  region,  and  to  fever.  But  it  is  associated  with  dis- 
turbance of  the  uterine  functions,  with  characteristic  ovarian  pain, 
and  occasions  no  perceptible  swelling.  A  tumor  of  the  ovary  or  of 
the  uterus  may  produce  a  visible  tumefaction ;  but,  springing  as  it 
does  out  of  the  pelvis,  its  exact  seat,  its  bulk,  its  shape,  the  absence 
of  marked  intestinal  symptoms,  and  a  vaginal  examination,  will  permit 
its  cause  to  be  discovered.  In  acute  sal])ingitis  there  is  the  history  of 
infection,  absence  of  vomiting,  and  but  slight  degree  of  abdominal 
tenderness  and  rigidity. 

Extrauterine  pregnancy  may  be  mistaken  for  acute  appendicitis  in 


538  MEDICAL  DIAGNOSIS. 

consequence  of  the  sudden  rupture  of  a  sac.  But  the  previous  his- 
tory, the  great  prostration,  the  excessive  thirst,  and  a  pelvic  exami- 
nation will  explain  the  true  meaning  of  the  symptoms.  In  pelvio 
hcemotocele  the  pain  and  the  suddenness  of  the  attack  make  us  think 
of  acute  appendicitis.  But  the  tumor  that  forms  is  generally  larger, 
doughy ;  there  are  no  localized  spots  of  tenderness,  no  marked  intes- 
tinal symptoms ;  and  the  history  of  irregular  menstruation  and  a 
vaginal  examination  will  remove  all  doubt.  Ovarian  cysts  v^^ith 
twisted  pedicle,  ovarian  abscess,  pyosalpinx,  fibroid  tumors,  a  vari- 
cose condition  of  the  veins  of  the  broad  ligament,  and  painful  men- 
struation may  also  be  mistaken  for  appendicitis ;  but  as  Deaver,^  in 
an  admirable  paper  based  on  extraordinarily  large  experience,  shows, 
none  has  the  exact  combination  of  signs  found  in  appendicitis.  This 
may  exist  as  a  complication  of  pregnancy. 

Generally  in  diseases  of  the  gall-bladder  the  seat  of  pain  and  ten- 
derness is  over  it,  and  not  in  the  right  iliac  fossa,  as  in  appendicitis. 
But  there  are  exceptions  in  both  affections,  rendering  the  diagnosis 
very  difficult,  it  may  be  impossible.  The  swelling  of  a  distended 
gah-bladder  may  be  felt  very  low  down,  and,  on  the  other  hand, 
appendicitis  of  the  upper  part  may  have  its  local  signs  in  the  neighbor- 
hood of  the  gall-bladder.  Rigidity  of  the  rectus  muscle  and  pain  are 
common  to  gall-bladder  disease  and  to  appendicitis.  The  pain  of 
acute  cholecystitis  is,  however,  more  violent ;  and  so  it  is,  as  a  rule, 
in  perforation  of  the  gall-bladder  than  in  perforative  appendicitis. 
Still,  how  deceptive  symptoms  may  be  is  proved  by  the  published 
cases  of  eminent  surgeons  like  Fowler  ^  and  like  Richardson.^ 

An  abscess  in  the  abdominal  walls  furnishes  very  many  of  the  signs 
of  abscess  around  the  appendix.  The  most  trustworthy  point  of 
distinction  is  that  the  former  moves  with  the  abdominal  walls  and  is 
unassociated  with  intestinal  irritation,  while  the  latter  is  commonly 
so  combined.  Then  the  peculiar  spots  of  tenderness,  the  outline  of 
the  swehing,  its  want  of  prominence,  are  unlike  what  is  found  in 
abscess  of  the  abdominal  walls. 

In  psoas  abscess  we  have  the  association  with  caries  of  the  verte- 
bras :  rigidity  or  an  excurvation  of  the  spine,  dorsal  pain  and  tender- 
ness, testify  to  this  connection.  It  occurs  in  scrofulous  persons,  and, 
although  gradual  in  its  formation,  is  often  sudden  in  its  manifestation  ; 
for  not  unusually  a  fluctuating,  painless  tumor  appears  below  Pou- 


1  Appendicitis  in  Relation  to  the  Diseases  of  Uterine  Adnexa  and  Pregnancy^ 
Medical  News,  Oct.  1897. 

2  Op.  cit.  ^  Amer.  Journ.  Med.  Sci.,  July,  1898. 


DISEASES  OF  THE  INTESTINES  AND   PERITONEUM.       539 

part's  ligament  as  the  first  positive  sign  of  this  formidable  affection. 
This  is  very  different  from  the  history  of  an  appendicitis  which  has  led 
to  post-csecal  abscess.  Moreover,  preceding  the  pointing  of  the  psoas 
abscess  at  the  spot  mentioned,  there  are  often  indications  of  u'ritation 
in  those  muscles  in  the  sheath  of  which  the  pus  travels ;  there  is  diffi- 
culty in  extending  the  leg,  with  inability  to  stand  upright. 

Pelvic  peritonitis  is  not  likely  to  be  mistaken  for  appendicitis,  except 
in  those  rare  cases  in  which  the  appendix  is  lodged  in  the  pelvis. 
Treves  ^  mentions  such  a  case.  He  also  cites  one  of  tuberculous  peri- 
tonitis the  cause  of  error.  While  the  local  signs  may  be  misleading, 
the  previous  history,  the  amount  of  fever,  and  the  grave  constitutional 
symptoms  are  likely  to  aid  us  to  a  correct  conclusion.  In  hip-joint 
disease  the  inclination  of  the  pelvis,  and  the  inability  to  move  the  joint 
normally,  furnish  trustworthy  points  of  distinction. 

It  is  sometimes  difficult  to  distinguish  between  appendicitis,  espe- 
cially ill  its  chronic  forms,  and  abscess  of  the  liver.;  the  more  difficult 
because,  as  I  know  by  experience,  they  may  coexist,  the  hepatic 
abscess  being  consequent  to  the  appendicitis.  Another  fact  that 
makes  the  diagnosis  difficult  is  that  the  pain  and  tenderness  in  appen- 
dicitis do  not  always  exist  in  the  right  iliac  fossa,  but  may  be  found  at 
various  parts  of  the  abdomen ;  the  abscess  following  appendicitis  may 
extend  high  up  towards  the  liver.  In  these  difficult  instances  the  his- 
tory of  the  case,  as  well  as  the  study  of  the  sequence  in  which  the 
phenomena  appeared,  becomes  of  the  greatest  value. 

A  distention  of  the  ccecum  may  be  mistaken  for  chronic  appendicitis. 
It  gives  rise  to  fulness  in  the  right  iliac  fossa,  and  to  pain,  often  of 
colicky  character,  but,  unless  associated  with  inflammation,  not  to 
tenderness  or  to  fever.  Purgatives,  too,  clear  out  the  faeces  which 
accumulate  from  want  of  power  of  the  bowel  to  propel  them,  and  the 
dulness  on  percussion  vanishes  after  the  free  evacuations,  and,  except 
when  the  caecum  is  loaded  with  faeces,  it  is  highly  tympanitic. 

In  that  rare  disease,  cancer  of  the  ccecum,  there  is  a  fixed,  firm 
swelling ;  but  it  is  of  very  gradual  growth,  and  the  disorder  generally 
produces  a  stricture  of  the  bowel  and  is  associated  with  malignant 
disease  in  other  parts  of  the  body. 

Other  affections  than  those  of  the  bowels  may  give  rise  to  signs 
supposed  to  indicate  appendicitis.  It  does  not  at  first  sight  seem 
likely  that  this  would  be  the  case  with  j^neiimonia.  Yet  the  mistake 
has  been  committed.  Pain  is  sometimes  referred  to  the  right  groin  in 
pneumonia,  and  there  is  soreness  there,  connected  probably  with  the 

^  Allbutt's  System  of  Medicine,  vol.  Hi.,  article  "Perityphlitis." 


540  MEDICAL  DIAGNOSIS. 

efforts  at  coughing  and  the  disordered  breathing.  Nay,  I  have  known 
poultices  to  be  apphed  to  the  right  iliac  fossa  to  relieve  the  inflam- 
mation which  really  was  in  the  chest.  An  examination  of  this  part 
of  the  body  will,  of  course,  at  once  explain  the  true  character  of  the 
symptoms. 

Hysteria  may  take  on  the  form  of  appendicitis,  but  there  is  no 
accurately  locahzed  tenderness  and  swelling,  nor  fever.  The  wide 
discussion  of  the  subject  of  appendicitis  and  the  popular  interest 
taken  in  it  have  led  to  a  new  form  of  hypochondriasis. 

In  chronic  appendicitis  there  is  at  times  a  strong  tendency  shown 
to  recurring  acute  or  subacute  attacks.  In  one  instance  that  came 
under  my  observation  there  were  forty-seven  before  the  case  was 
operated  on.  Generally  in  these  cases  of  recurring  appendicitis  a 
chronic  thickening  of  the  appendix  is  present  with  or  without  adhe- 
sions, and  the  tube  is  narrowed  or  obliterated ;  there  is  obliterative 
appendicitis.  An  induration  may  nearly  always  be  felt  in  the  region 
of  the  appendix,  and  there  is  tenderness  on  deep  pressure,  and  mostly 
some  impairment  of  general  health  and  symptoms  of  intestinal  dys- 
pepsia. Indiscretions  in  diet  or  active  exercise  is  very  apt  to  bring  on 
an  acute  attack,  and  perforation  may  be  the  outcome  of  many. 

Disorders  attended  with  Constipation,  and  of  which  it  is  a 
Prominent  Symptom. 

An  inactive  state  of  the  bowels  is  often  but  a  concomitant  of  some 
disorder  which  presents  much  more  striking  phenomena.  But  there 
are  cases  in  which  the  constipation  is  the  most  important  symptom, 
and  in  which  it  furnishes  decisive  proof  of  a  morbid  condition  of  the 
intestine.  Now,  these  cases  are  either  those  in  which  the  constipation 
arises  suddenly,  or  at  any  rate  becomes  suddenly  aggravated,  and  is 
often  insuperable  ;  or  those  in  which  it  is  an  habitual  state,  and  is  not 
associated  with  any  signs  of  urgent  distress. 

Intestinal  Obstruction. — Intestinal  obstruction,  when  coming 
on  suddenly,  manifests  itself  generally  in  the  following  manner :  A 
person,  previously  in  good  health,  or  perhaps  of  costive  habit,  notices 
that  his  bowels  have  not  been  moved  for  several  days,  and  that  he  has 
an  uneasy  feeling  in  the  abdomen  in  consequence.  He  takes  the  pur- 
gative he  is  wont  to  employ,  but  without  the  usual  effect.  Something 
more  active  is  tried,  and' still  the  bowels  remain  obstinately  bound. 
Severe  colicky  pains  have  in  the  mean  time  made  their  appearance. 
He  becomes  alarmed,  and  sends  for  his  physician,  who  sees  that  there 
is  indeed  cause  for  alarm.  The  abdomen  is  found  to  be  distended,  but 
not  painful,   or  only  slightly  painful,   on   pressure.     But  through  its 


DISEASES   OF  THE  INTESTINES  AND   PERITONEUM.       541 

parietes  may  be  noticed  the  violent,  rolling  motion  of  the  irritated  in- 
testine. Vomiting  sets  in, — first,  of  the  substances  contained  in  the 
stomach  or  of  a  bilious  fluid,  and,  as  the  case  progresses,  of  ster- 
coraceous  matter.  In  this  way,  unless  nature  or  art  comes  to  the 
rescue,  the  disease  continues ;  and  signs  of  inflammation  of  the 
bowels,  and  with  them  fever,  appear  as  preludes  to  the  fatal  termina- 
tion. Sometimes,  however,  the  patient  becomes  gradually  exhausted ; 
there  are  no  tenderness  and  fever,  but  a  cool  skin,  a  quick,  small 
pulse,  a  countenance  ghastly  and  panic-stricken.  Violent  paroxysms 
of  pain,  alternating  with  intervals  of  ease,  may  occur  to  the  last 
moment.  But,  in  spite  of  the  utter  prostration,  the  mind  generally 
retains  its  clearness.  Should  recovery  take  place,  large  quantities 
of  fecal  matter  are  discharged,  and  the  symptoms  of  the  impediment 
speedily  disappear. 

These  phenomena  are  too  striking  to  permit  of  errors  in  diagnosis. 
Yet  errors  are  of  frequent  occurrence,  because  the  history  of  the  at- 
tack and  the  sequence  of  the  symptoms  are  not  taken  into  account. 
Many  a  person  laboring  under  peritonitis  has  been  violently  purged  to 
remove  the  stubborn  constipation  believed  to  be  due  to  a  mechanical 
hinderance  in  the  bowels ;  and,  on  the  other  hand,  many  a  case  of 
intestinal  obstruction  has  been  treated  solely  with  reference  to  the 
inflammation  that  may  attend  it,  and  without  regard  to  the  source  of 
the  inflammation.  Yet  it  is  not  ordinarily  difficult  to  distinguish 
which  is  cause  and  which  effect.  A  case  that  begins  with  severe 
colicky  pains  and  obstinate  constipation,  in  which,  at  first,  in  spite  of 
the  pain,  there  is  little  or  no  tenderness  ;  in  which  the  temperature  is 
normal  or  subnormal ;  in  which  vomiting  and  tympany  soon  occur  ;  in 
which  fulness  on  palpation  and  dulness  on  percussion  may  be  detected 
at  or  above  the  point  of  stoppage  ;  and  in  which  fecal  matter  is  ejected 
by  the  mouth  after  a  stoppage  of  the  bowels  of  a  few  days'  duration, 
— is  not  primarily,  whatever  may  be  the  ultimate  complications, 
enteritis  or  peritonitis.  A  case  presenting  almost  from  the  onset  fever 
and  great  and  extended  tenderness,  in  which  vomiting  of  fecal  matter, 
if  it  happen  at  all,  does  not  happen  until  late ;  in  which  diarrhoea  is 
sometimes  found  to  supersede  the  enduring  constipation, — is  inflam- 
mation of  the  peritoneum,  but  not  a  mechanical  obstruction.  Only 
in  rare  instances,  and  especially  when  the  bowel  is  invaginated,  is  the 
malady  so  quickly  succeeded  by  inflammation  as  seemingly  to  make 
its"  appearance  with  the  signs  of  peritonitis.  Perforative  peritonitis, 
with  its  signs  of  collapse,  shows  a  much  stronger  likeness  to  acute 
obstruction  of  the  bowel  than  ordinary  peritonitis  does. 

The  symptoms  dwelt  upon  as  pointing  to  an  intestinal  obstruction 

34 


542  MEDICAL  DIAGNOSIS. 

bear  a  close  resemblance  to  those  of  external  strangulated  hernia.  In 
truth,  they  not  only  resemble  but  are  identical  with  those  of  this  affec- 
tion. Hence  in  every  case  of  obstinate  constipation  each  point  which 
may  be  the  seat  of  a  hernia  must  be  explored  by  the  eye  and  the 
hand.  No  motives  of  false  delicacy,  no  reluctance,  should  prevent 
the  physician  from  insisting  on  a  search,  the  neglect  of  which  may 
cost  a  life. 

It  would  be  foreign  to  the  object  of  this  work  to  discuss  the  exter- 
nal signs  by  which  a  strangulation  of  the  intestine  at  a  hernial  open- 
ing manifests  itself.  It  need  only  be  mentioned  that  it  is  at  the  groin, 
at  the  umbilicus,  at  the  side  of  the  anus,  or  through  the  ischiatic 
notch  that  the  gut  descends  and  forms  a  tumor,  and  that  these  are, 
therefore,  the  regions  to  be  scrutinized.  Moreover,  there  are  internal 
hernias  that  become  strangulated,  such  as  a  diaphragmatic  hernia,  a 
hernia  into  the  foramen  of  Winslow.  But  these  are  matters  more 
strictly  surgical.  Yet  there  is  one  part  of  the  subject,  of  importance 
alike  to  the  physician  and  to  the  surgeon,  which  cannot  be  passed  by 
without  a  few  words,  since  it  may  be  a  cause  of  much  perplexity, — 
namely,  the  possibility  of  intestinal  obstruction  taking  place  in  a 
person  laboring  under  an  irreducible  hernia  and  simulating  strangu- 
lation without  any  strangulation  having  occurred.  Of  this  the  fol- 
lowing case  furnishes  an  example. 

A  number  of  years  since  I  was  requested  by  a  physician  to  see 
with  him  a  woman,  the  mother  of  thirteen  children,  who  had  been 
for  days  laboring  under  obstinate  constipation.  Large  doses  of  mer- 
curials, croton  oil,  and  turpentine  enemata  had  failed  to  procure  a 
passage,  and  the  patient  was  becoming  much  frightened.  Nor  was 
her  situation  free  from  danger.  She  had  considerable  pain  in  the 
abdomen  ;  she  had  been  vomiting  stercoraceous  matter  profusely ; 
the  rolling  of  the  intestines  could  be  plainly  perceived.  On  her  right 
side  was  a  small  irreducible  femoral  hernia,  which  had  existed  for 
years.  It  was  not  painful  on  pressure,  nor  was  the  skin  discolored ; 
neither  did  the  mass  itself  communicate  an  impulse  during  the  act 
of  coughing.  Here  were  signs  of  a  serious  impediment  to  the  onward 
passage  of  the  intestinal  contents,  as  the  fecal  vomiting  and  the  rolling 
of  the  intestines  showed  plainly.  But  was  it  due  to  strangulation  at 
the  hernial  opening  ?     Was  it  an  internal  intestinal  obstruction  ? 

An  accurate  examination  of  the  abdomen  did  not  throw  much 
light  on  these  questions.  The  belly  was  moderately  tympanitic,  and 
not  painful  to  the  touch,  except  when  the  pressure  was  considerable. 
The  rolling  of  the  intestines  was  perhaps  more  obvious  on  the  left 
side ;   but  nowhere  could  a  tumor  be  felt.     Taking  all  the  circum- 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       543 

stances  of  the  case  into  account, — the  fact  that  the  patient  was  of  cos- 
tive habit ;  that  she  was  subject  to  attacks  of  colic  and  of  obstinate 
constipation;  that  there  was  nothing  to  prove  that  the  hernia  had 
recently  increased,  or  was  in  any  way  inflamed, — the  conclusion  ar- 
rived at  was  that  the  case  was  not  one  of  hernial  strangulation,  but 
of  internal  intestinal  obstruction.  Copious  warm-water  injections 
were  thrown  into  the  colon  through  a  flexible  tube  ;  her  abdomen  was 
rubbed  with  mercurial  ointment.  But  all  in  vain :  she  continued 
vomiting  fecal  matter. 

Her  situation  now  appeared  desperate.  She  had  not  had  a  pas- 
sage for  six  days  ;  she  was  steadily  sinking.  Knowing  that  sometimes 
the  gut  may  be  strangulated  at  a  hernial  opening  without  much  pain 
or  tenderness,  the  counsel  of  an  eminent  surgeon  was  sought,  to  aid 
in  determining  whether  this  was  not  the  cause  of  the  impediment. 
He  thought  it  probable  that  it  was.  The  patient  was  etherized,  and 
the  hernial  section  performed ;  but  no  constriction  was  found.  The 
wound  was  closed,  and  large  doses  of  opium  were  administered,  so  as 
to  mitigate,  so  far  as  practicable,  the  torture  of  the  only  termination  to 
the  case  which  seemed  possible.  On  the  day  after  the  operation,  the 
intestines  had  ceased  to  roll ;  there  was  no  vomiting.  But  stercora- 
ceous  vomiting  reappeared  two  days  afterwards,  and  the  rolling  of  the 
intestines  was  occasionally,  although  faintly,  perceptible. 

The  patient's  exhaustign  was  now  extreme ;  her  pulse  was  very 
quick  and  small ;  her  skin  cold,  of  a  dirty  look ;  the  odor  of  the 
breath  and  of  the  whole  body  offensive ;  and  the  eyes  sunken  and 
surrounded  by  a  broad  leaden  ring.  There  was  slight  pain  on  press- 
ure between  the  umbilicus  and  the  sigmoid  flexure.  The  vomiting 
had  ceased,  or  occurred  only  occasionally.  Although  there  was  little 
hope,  we  had,  as  soon  as  admissible  after  the  operation,  recommenced 
rubbing  mercurial  ointment  over  the  abdomen,  and  giving  injections  in 
the  manner  before  described.  This  was  continued  until,  to  our  great 
gratification,  one  morning,  after  a  tube  had  been  passed  a  distance  of 
several  feet  into  the  colon,  the  patient  had  a  copious  discharge  of  tarry 
fecal  matter  from  her  bowels, — seventeen  days  after  the  symptoms  of 
complete  intestinal  obstruction  had  declared  themselves  by  the  occur- 
rence of  stercoraceous  vomiting.  . 

This  case  is  instructive  in  more  than  one  respect.  It  teaches  that 
recovery  may  take  place  most  unexpectedly  after  many  days  ;  and,  in 
a  diagnostic  point  of  view,  it  illustrates  a  difficulty  which  any  physi- 
cian may  have  to  encounter  in  attending  a  patient  the  subject  of  a 
long-standing  hernia. 

Supposing  that  the  symptoms  are  altogether  owing  to  an  obstacle 


544  MEDICAL  DIAGNOSIS. 

at  some  portion  of  the  intestine  within  the  abdomen ;  can  we  deter- 
mine the  exact  position  of  the  impediment  and  its  nature  ?  We  know 
how  varied  are  the  conditions  which  lead  to  sudden  and  invincible 
constipation.  We  know  that  strangulation  from  bands  and  adhesions, 
or  gaps  in  the  omentum,  or  the  pedicle  of  an  ovarian  tumor ;  that 
intussusception  ;  that  twists  and  knots  ;  that  strictures  and  tumors  ; 
that  abnormal  contents,  such  as  foreign  bodies,  impacted  faeces,  gall- 
stones, worms,  concretions  of  drugs,  as  of  bismuth,  may  all  occasion 
intestinal  obstruction.  We  also  know  that  in  certain  cases  the  ob- 
struction is  from  spasmodic  contraction  of  the  intestine,^  or  paralysis 
of  the  bowel.  Can  we  distinguish  these  different  lesions  at  the  bed- 
side ?  In  certain  cases  we  can, — we  can  determine  exactly  both  the 
position  and  the  character  of  the  lesion ;  in  others  there  is  no  clue 
to  an  accurate  discernment  of  either.  It  is  possible  that  in  time  the 
X-rays  may  give  us  the  desired  information. 

Obstruction  of  the  bowel  may  present  itself  as  an  acute  or  as  a 
chronic  malady.  The  same  symptoms  occur  in  both.  It  is  the  mode 
of  origin  that  is  different.  Nay,  the  same  lesion  may  occasion  in  some 
instances  an  acute,  in  others  a  chronic,  affection.  Intussusception, 
internal  strangulation,  volvulus,  impaction  of  a  large  gall-stone,  are 
generally  acute ;  strictures,  tumors,  contractions,  and,  for  the  most 
part,  fecal  accumulations,  lead  to  chronic  obstruction.  Then  there  are 
cases  that  pursue  a  chronic  course,  but  which  terminate  in  acute  ob- 
struction. In  acute  intestinal  obstruction,  the  first  marked  symptom  is 
violent  abdominal  pain  in  the  region  of  the  umbilicus  ;  there  are  early 
and  persistent  vomiting  which  becomes  stercoraceous,  great  thirst, 
and  often  speedy  collapse.  Unless  peritonitis  supervene,  we  find  no 
fever ;  towards  the  end  the  signs  of  septic  poisoning  may  show  them- 
selves. In  chronic  intestinal  obstruction  the  pain  is  at  first  like  ordi- 
nary colic,  and  gradually  becomes  more  persistent ;  nausea  is  almost 
constant,  but  vomiting  is  not,  except  towards  the  end,  a  pronounced 
feature,  and  the  constipation  only  gradually  becomes  absolute.  The 
abdomen  is  distended  and  the  seat  of  gurgling  sounds,  tenesmus  is 
common,  and  a  tumor,  often  the  result  of  fecal  accumulation,  can  be 
felt.  The  breath  acquires  a  fecal  odor;  the  appetite  utterly  fails. 
Unless  the  obstruction  can  be  relieved,  the  patient  dies  worn  out,  and 
from  ptomaine-poisoning. 

We  shall  first  examine  the  more  common  kinds  of  the  acute 
form.  Among  these,  intussusception  or  invagination  is  frequent  and 
at  the  same  time  the  least  difficult  of  recognition.     Part  of  the  bowel 


Archives  Generales,  Aug.  1868  ;  Flint,  Practice  of  Medicine. 


DISEASES  OF  THE   INTESTINES  AND  PEEITONEUM.       545 

becomes  inverted,  slipping  into  the  cavity  of  the  adjoining  upper  or 
lower  portion.  Inflammation  is  soon  set  up,  produces  infiltration  of 
the  tissues,  and  often  leads  to  adhesions  between  the  opposed  serous 
surfaces.  The  inflammation  may  spread  rapidly  over  the  serous 
membrane,  and  the  patient  may  die  from  general  peritonitis.  But 
sometimes  in  the  inflammation  that  is  lighted  up  at  the  seat  of  the 
ileus  lies  safety.  It  may  give  rise  ultimately  to  a  sloughing  off  of  the 
invaginated  part  and  its  discharge  into  the  bowel,  while  the  mass  of 
adhesive  lymph  surrounding  the  seg.t  of  ulceration  maintains  the  con- 
tinuity of  the  intestinal  canal ;  thus  the  inflammation  may  pave  the 
way  to  a  favorable  issue  by  restoring  the  caliber  of  the  tube, — suffi- 
ciently, at  any  rate,  to  permit  of  the  transit  of  its  contents. 

When  the  intussusception  takes  place  rapidly,  a  sudden  local  pain 
is  produced,  recurring  in  paroxysms,  and  likely  to  be  referred  to  the 
seat  of  the  disturbance.  The  pain  is  quickly  followed  by  vomiting, 
by  constipation,  by  tympany,  and  by  tenderness.  But  the  constipa- 
tion is  not  so  absolute  as  in  other  cases  of  intestinal  impediment ;  is, 
indeed,  often  preceded  by  diarrhoea.  Not  unusually,  owing  to  the 
invaginated  bowel  remaining  open,  the  lic{uid  contents  of  the  intes- 
tine pass  through  the  intussuscepted  part  and  produce  a  deceptive 
diarrhoea ;  yet  oftener  occur  tenesmus  and  discharges  of  bloody 
mucus.  Both  of  the  latter  signs  are  eminently  diagnostic  of  the 
lesion.  Still  more  so  is  feeling  the  end  of  the  invaginated  bowel  by 
an  exploration  of  the  rectum,  or  finding  the  loosened  segment  in  the 
stools.  But  it  is  only  in  cases  in  which  the  lower  portion  of  the 
canal  is  affected,  or  which  have  been  sufficiently  protracted  to  allow 
of  the  curative  efforts  of  nature  being  accomplished,  that  signs  so 
pathognomonic  are  met  with.  Vomiting  is  not  a  marked  feature  of 
acute  intussusception ;  it  sometimes  passes  away  and  returns.  The 
tenderness  at  first  is  localized,  but  spreads  as  peritonitis  spreads ; 
there  is  rarely  tympany. 

The  casting  off  of  the  sloughed  portion  of  the  intestine  is  attended 
with  hemorrhage.  Whether  this  be  the  only  cause  of  the  hemorrhage 
or  not,  it  is  undoubted  that  purging,  or  sometimes  vomiting,  of  blood, 
is  among  the  differential  signs  of  intussusception.  A  sign  more  valu- 
able, because  so  much  more  usual,  and  present  in  about  half  the 
cases,  is  a  tumor,  frequently  of  cylindrical  shape.  Its  seat  varies 
with  the  seat  of  the  lesion  ;  and  as  the  most  common  invaginations 
are  those  of  the  ileum  and  c?ecum  into  the  colon,  or  those  at  the 
inferior  portion  of  the  ileum,  it  is  at  the  lower  part  of  the  belly,  and 
in  the  right  iliac  fossa,  that  the  swelling  is  detected.  In  the  attacks  of 
pain,  the  tumor  becomes  harder  and  larger.     When  low  down  in  the 


546  MEDICAL  DIAGNOSIS. 

rectum,  or  protruding  from  it,  it  has  been  mistaken  for  hemorrhoids 
or  prolapse  of  the  bowel. 

The  malady  is  generally  due  to  irregular  peristalsis  ;  it  is  some- 
times caused  by  tumors  of  the  mtestines,  particularly  by  lipoma.^ 
The  majority  of  cases  of  invagination  happen  in  children  under  ten 
years  of  age,  and  a  number  are  met  with  in  infants.  The  course  the 
affection  pursues  is  rapid ;  the  patient  dies  generally  in  less  than  a 
week  after  the  occurrence  of  the  accident,  utterly  prostrated.  The 
cases  which  get  well  recover  eit^ier  gradually  after  the  invaginated 
bowel  has  been  discharged,  or,  in  rare  instances,  quickly  by  the 
inverted  bowel  righting  itself. 

Acute  obstruction  from  internal  strangulation,  as  by  bands  or 
through  apertures,  is  almost  invariably  seated  in  the  small  intestine. 
Its  most  characteristic  feature  is  furnished  by  the  history  of  a  previ- 
ous peritonitis,  an  operation  on  the  abdomen,  or  an  appendicitis. 
There  is  rarely  fever ;  the  obstruction  has  a  sudden  onset  and  soon 
becomes  complete ;  nausea  and  vomiting  set  in  early ;  fecal  vomiting 
usually  begins  from  the  third  to  the  fifth  day.  It  is  the  decided 
exception  to  find  a  tumor ;  tympany  may  or  may  not  be  marked,  but 
no  flatus  escapes  by  the  bowel.  Of  further  significance  in  the  diag- 
nosis of  internal  strangulation  are  the  occurrence  of  collapse  almost 
from  the  beginning ;  the  frequency  with  which  the  disease  is  found  in 
young  adults ;  the  rapid  course  it  runs  ;  the  severity  of  the  pain, 
which  is  generally  referred  to  the  umbilicus ;  the  intense  thirst ;  the 
absence  of  external  or  of  discoverable  obturator  hernia ;  the  absence 
of  visible  peristole, — such  as  happens  in  stricture, — of  tumor,  of  hem- 
orrhage, of  tenesmus,  and  of  dysenteric  symptoms,  as  seen  in  intus- 
susception. Obstruction  by  a  band  connected  with  a  diverticulum 
scarcely  ever  occurs  except  in  males  under  twenty  years  of  age.^ 

Acute  obstruction  from  volvulus  or  twist  begins  with  severe  ab- 
dominal pain,  which  soon  becomes  associated  with  nausea  and  vomit- 
ing and  extreme  distention ;  it  rarely  presents  a  tumor  or  visible 
intestinal  coils,  or  elevation  of  temperature.^  It  nearly  always  affects 
the  sigmoid  flexure,  and  is  preceded  by  a  history  of  constipation  ;  the 
pain  at  first  is  intermittent.  There  is  local  tenderness  over  the  dis- 
tended colon,  also  tenesmus  ;  vomiting  may  be  absent.  The  meteor- 
ism  is  very  great,  and  peritonitis  soon  becomes  a  complication.     The 

^  Clos„De  rinvagination  intestinale,  etc.,  Paris,  1883. 
^  Fagge,  Practice  of  Medicine,  vol.  ii. 

^  Fitz,   Acute    Intestinal    Obstruction,   Transactions    of   Congress    of  American 
Physicians  and  Surgeons,  vol.  i.,  1889. 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       547 

constipation  is  absolute.  Tenesmus  and  dyspnoea  are  not  infrequent. 
It  is  commonly  met  with  in  men  after  forty  years  of  age. 

Obstruction  by  a  large  gall-stone  is  apt  to  occasion  severe  attacks 
of  colic  as  the  gall-stone  passes  along  the  course  of  the  small  intes- 
tine, and  is  temporarily  arrested.  There  is  also  vomiting,  but  no  de- 
cided abdominal  tenderness,  and  no  tumor.  Similar  but  less  severe 
symptoms  may  happen,  with  periods  of  entire  relief,  until  the  gall- 
stone becomes  impacted,  and  the  constipation  absolute.  We  shall  be 
greatly  assisted  in  the  diagnosis  by  the  history  of  previous  biliary 
colic,  particularly  if  the  symptoms  are  met  with  in  a  fat,  elderly 
woman.^  The  signs  of  intestinal  stone,  or  enterolith^  are  those  of  a 
gradual  and  chronic,  and  not  of  an  acute,  obstruction.  Obstruction 
from  the  swelling  of  a  foreign  body  that  has  become  impacted  in  the 
intestine  can  only  be  discriminated  by  the  history. 

There  are  other  and  rarer  forms  of  lesions  than  these  discussed  as 
leading  to  acute  obstruction,  especially  connected  with  the  different 
results  of  adhesions  and  matting  together  of  the  intestinal  coils,  but 
there  is  nothing  in  the  symptoms  to  guide  us  in  deciding  on  the  exact 
nature  of  the  obstacle. 

Chronic  obstruction  of  the  bowel  is  generally  produced  by  fecal 
accumulations,  by  chronic  intussusception,  or  by  strictures.  Chronic 
obstruction  from  fecal  accumulations  occurs  chiefly  in  women,  espe- 
cially neurotic  women.  There  is  the  history  of  a  long-standing  con- 
stipated habit,  with  attacks,  perhaps  deceptive,  of  catarrhal  diarrhoea, 
produced  by  the  irritation  from  the  hardened  faeces,  with  offensive 
breath,  at  times  with  slight  fever.  Pain  and  vomiting  occur  as  late 
symptoms,  and  a  tumor  or  tumors  are  noticed  in  any  part  of  the 
large  intestine.  The  tumor  is  usually  painless,  and  has  a  doughy  feel ; 
the  abdomen  is  very  distended ;  but,  except  the  occlusion  be  low 
down  in  the  descending  colon,  there  is  no  tenesmus.  The  consti- 
pation gradually  increases,  and,  unless  relieved,  becomes  insuperable. 
Fortunately,  it  generally  can  be  relieved. 

Chronic  intussusception  may  extend  over  months.  The  symptoms 
are  much  the  same  as  in  the  acute  form,  save  that  tenesmus  is  less 
common.  Tumor,  as  in  acute  intussusception,  is  present  in  about 
half  the  cases.  Paroxysmal  pain  and  diarrhoea  are  generally  promi- 
nent, vomiting  is  not.  Blood  is  frequently  passed  with  the  stools. 
The  patient  is  apt  to  die  from  exhaustion. 

Strictures  of  the  bowels  are  generally  cancerous.  They  mostly 
occur  after  the  age  of  forty,  and  are  of  slow  development.'    The  ob- 


^  Fagge,  Practice  of  Medicine,  vol.  ii.  p.  210. 


548  MEDICAL  DIAGNOSIS. 

struction  is  shown  by  the  alteration  in  the  shape  and  size  of  the  fecal 
discharges,  wliich  become  flattened.  But  this  is  far  from  an  invariable 
rule.  In  the  majority  of  cases  the  stricture  is  at  the  sigmoid  flexure, 
and  often  at  its  lower  part.  There  are  paroxysms  of  pain,  disten- 
tion of  the  abdomen,  and  attacks  of  constipation  that  become  more 
and  more  protracted  until  obstruction  occurs,  unless  death  take  place 
previously  from  the  cachexia.  Vomiting  happens  only  as  a  late  symp- 
tom. Tenesmus,  bloody  discharge  from  the  bowel,  and  hemorrhoids 
are  often  met  with.  Treves  ^  states  that  tenesmus  is  more  marked 
early  than  late  in  the  disease.  In  malignant  cases  we  can  generally 
feel  a  tumor  through  the  abdominal  walls.  If  in  addition  to  the 
symptoms  enumerated,  a  bougie  passed  mto  the  rectum  meet  in  its 
course  with  a  decided  obstacle,  an  error  in  diagnosis  is  hardly  pos- 
sible. When,  however,  the  stricture  is  not  accessible  to  instrumental 
examination,  although  we  can  commonly  recognize  its  presence,  we 
cannot  fix  its  site.  The  distention  above  the  narrowed  part  is  often 
so  extreme  as  to  lead  to  displacement  of  the  colon  and  to  an  almost 
uniform  swelling  of  the  whole  abdomen.  For  mstance,  in  a  case  re- 
ported by  Albert  H.  Smith,  the  enormously  dilated  colon  had  broken 
loose  from  its  attachments  and  concealed  the  rest  of  the  viscera.  It 
was  in  several  places  eighteen,  in  none  less  than  fifteen,  inches  in 
circumference.^ 

Other  causes  of  stricture  besides  cancer,  though  less  common  ones, 
are  cicatrization  of  extensive  syphilitic,  tuberculous,  or  dysenteric 
ulcers.  Save  in  the  tuberculous  form,  there  is  not  marked  cachexia, 
and  a  tumor  can  rarely  be  felt.  Obstruction  produced  by  the  pressure 
of  tumors  external  to  the  bowels  cannot  be  distinguished  from  that 
due  to  intestinal  stricture,  except  it  be  by  the  antecedent  circum- 
stances.  In  all  cases  of  constriction  of  the  small  intestine,  however 
caused,  there  are  signs  of  indigestion  and  colicky  pains.  Tenesmus 
does  not  happen,  but  vomiting  is  more  common  than  in  stricture  of 
the  large  bowel.  A  contraction  in  the  small  intestme  is  seen  chiefly 
as  the  result  of  chronic  peritonitis  binding  down  the  bowel,  and  may 
lead,  like  a  stricture,  to  chronic  obstruction.^  Fecal  accumulations  also 
produce  chronic  obstruction. 

With  reference  to  the  frequency  of  the  different  forms  of  intestinal 
obstruction,  the  elaborate  studies  of  Fitz^  give  us  valuable  informa- 


^  Article  "Intestinal  Obstruction,"  AUbutt's  System  of  Medicine. 

^  Proceedings  of  the  Pathological  Society  of  Philadelphia,  Dec.  1858,  vol.  i. 

'  Fagge,  Guy's  Hospital  Reports,  3d  Series,  vol.  xiv. 

*  Transact,  of  Congress  of  Amer.  Phys.  and  Surg.,  vol.  i.,  1889. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       549 

tion.  Strangulation  is  the  most  frequent  cause  of  acute  obstruction, 
occurring  in  fully  one-third  of  the  cases  ;  a  number  are  noted  as  fol- 
lowing operations  upon  the  pelvic  organs  in  women,  though  the  dis- 
ease is  very  much  more  common  in  men  than  in  women.  Intussus- 
ception comes  next  in  frequency,  and  is  especially  seen  among  children 
and  young  adults.  Volvulus  or  twist  is  mostly  encountered  in  men, 
and  in  half  the  cases  is  in  the  sigmoid  flexure.  Strictures  and  tumors, 
that  are  such  usual  causes  of  chronic  obstruction,  very  rarely  lead 
to  acute  obstruction.  Treves,^  from  an  examination  of  the  records  of 
the  London  Hospital,  regards  the  cases  due  to  fecal  accumulation  as 
the  most  numerous,  and  those  caused  by  intussusception  as  more 
common  than  those  from  strangulation. 

In  any  kmd  of  obstruction  the  location  of  the  lesion  is  difficult  to 
determine.  There  are,  however,  a  few  circumstances  which  may  aid 
us  in  arriving  at  such  a  determination :  one  is  the  fact  pointed  out  by 
Barlow,^  that  the  higher  up  the  obstruction  is  in  the  canal,  the  nearer 
therefore  to  the  stomach,  the  smaller  is  the  quantity  of  urine  passed ; 
another  is  the  early  and  more  persistent  occurrence  of  the  vomiting 
and  its  want  of  stercoraceous  character, — both  of  which  render  it 
likely  that  the  impediment  is  in  the  small  intestine  and  remote  from 
the  caecum.  Another  is  the  early  presence  and  the  greater  severity 
of  hiccough  when  the  mischief  is  in  the  small  intestine,  and  the  greater 
constitutional  disturbance.  Another  is  the  absence  of  tenesmus  ex- 
cept in  acute  intussusception.  Yet  another,  that  by  far  the  largest 
number  of  cases  of  acute  obstruction  have  the  lesion  in  the  small 
intestine,  while  in  the  chronic  ones  it  is  generally  in  the  large  bowel. 
Sometimes  the  patient  is  himself  aware  of  "the  exact  seat  of  the  cause 
of  his  suffering ;  he  notices  that  the  injecting  tube  or  the  enemata 
seem  to  reach  a  certain  point  and  go  no  farther ;  so,  also,  with  the 
rumbling  of  the  wind.  Again,  these  borborygmi  are  especially  apt  to 
occur  in  obstructions  of  the  large  intestines,  and,  if  joined  to  tenesmus, 
are  signs  of  some  importance.  Indican  is  found  in  the  urine  in 
greatly  increased  quantities  in  stoppages  of  the  small  intestine.  We 
may  also  be  able  to  come  to  some  conclusion  about  the  seat  of  the 
lesion  by  finding  out  how  many  quarts  of  warm  water  we  can  inject 
into  the  large  intestine. 

The  location  of  the  pain,  too,  may  furnish  a  clue  to  the  position  of 
the  impediment.     If  this  be  in  the  small  intestine,  the  pain  is  apt  to 

^  Loc.  cit. 

^  Guy's  Hosp.  Rep.,  2d  Series,  vol.  ii.  Brinton  accepts  this  statement  only  in 
so  far  as  the  amount  of  vomiting,  which  is  apt  to  be  greatest  when  the  obstruction 
is  high  up,  influences  the  amount  of  urine  passed. 


550  MEDICAL  DIAGNOSIS. 

be  chiefly,  if  not  entirely,  in  the  neighborhood  of  the  umbiHcus. 
Another  circumstance  on  which  some  stress  may  be  laid  is  the  disten- 
tion of  the  intestine  above  the  point  of  intussusception.  Indeed,  this 
distention  may  occasion  a  visible  fulness,  sounding  extremely  tym- 
panitic on  percussion  ;  at  times,  too,  a  slight  dulness  is  found,  attended 
with  some  resistance  at  or  immediately  above  the  seat  of  the  obstruc- 
tion. But  neither  the  swelling  nor  the  tympanitic  dilatation  of  the 
bowel — as  William  Brinton  ^  has  proved— is  a  certain  sign ;  indeed, 
with  the  exception  of  a  tumor  dull  on  percussion  and  resistant  to  the 
touch,  there  is  nothing  absolutely  indicative  of  the  lesion  being  at  a 
particular  spot.  It  is  hardly  necessary  to  say  that  a  swelling  of  this 
kind  cannot  always  be  found. 

Pain  and  swelling  in  the  right  iliac  fossa  may  be  caused  by  an 
appendicitis,  and  the  constipation  which  may  attend  is  most  obstinate 
and  in  some  instances  incurable,  causing  the  disease  to  enter  into  the 
category  of  intestinal  obstructions.  We  have  already,  when  treating 
of  appendicitis,  discussed  the  diagnosis  between  this  and  intestinal 
obstruction.  It  is  in  appendicitis  important  to  note  that  should  the 
constipation  have  become  unyielding,  the  tumor  and  the  other  local 
signs  do  not  follow  the  insuperable  constipation,  but  precede  it. 
Stress  may  be  laid  upon  the  occurrence  of  the  signs  of  collapse  in 
perforative  appendicitis,  though  these  may  be  slow  in  their  develop- 
ment. In  acide  hemori'hagic  pancreatitis  there  may  be  also  the  signs 
of  intestinal  obstruction,  not  to  be  distinguished  except  perhaps  by 
the  history,  the  extremely  rapid  course  of  the  disease,  and  the  marked 
peritonitis. 

Symptoms  like  those  of  intestinal  obstruction  may  also  result  from 
occlusion  of  the  mesenteric  arteries  by  thrombosis  or  embolism,  in  con- 
sequence of  atheroma  or  inflammation  of  the  vessels,  arteriosclerosis, 
or  valvular  disease  of  the  heart.  There  may  be  besides  severe  ab- 
dominal pain,  vomiting  that  may  become  stercoraceous  or  bloody, 
tympanites,  and  signs  of  collapse.  Instead  of  constipation  or  in  its 
sequence  there  may  be  diarrhoea,  with  bloody  stools.  Sometimes  a 
tumor  may  be  palpable.  The  affected  portion  of  bowel  may  undergo 
ulceration  or  gangrene. 

Habitual  Constipation. — This  is  a  chronic  state,  unattended 
with  urgent  symptoms  of  any  kind.  Yet  it  is  an  annoying  and  very 
prevalent  complaint.  The  symptoms  encountered,  independently  of 
the  rare  and  difficult  fecal  evacuations,  are  headache,  giddiness,  slug- 
gishness of  mind,  a  want  of  the  natural  appetite,  antemia,  cutaneous 


Croonian  Lectures,  and  work  on  Intestinal  Obstruction. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       551 

eruptions,  and,  joined  as  the  disorder  not  infrequently  is  to  derange- 
ment of  the  stomach  and  of  the  biliary  secretion,  digestive  disturb- 
ances and  a  sallow  complexion :  an  altered  state  of  the  blood  from 
the  absorption  of  ptomaines  may  exist.  In  women  there  are  also 
often  added  to  the  list  of  evils  to  which  costiveness  gives  rise, 
neuralgic  pains,  palpitation  of  the  heart,  cold  feet  and  hands.  Infre- 
quent evacuation  of  the  bowels  does  not  always  produce  such  un- 
pleasant consequences.  It  may,  indeed,  in  individual  cases  be  com- 
patible with  perfect  health  ;  for  what  is  costiveness  in  one  person  may 
be  a  natural  state  in  another.^ 

Habitual  constipation  is  produced  by  various  causes.  It  may  be 
brought  about  by  the  peculiar  nature  of  the  diet.  It  may  depend  upon 
a  deficiency  or  a  faulty  composition  of  the  intestinal  secretions,  or 
upon  disorders  of  those  neighboring  glands  which  pour  their  secre- 
tions into  the  intestines.  It  may  result  from  impaired  power  of  the 
bowel  to  propel  its  contents,  the  consequence  either  of  some  mechan- 
ical interference  with  its  action,  or  of  nervous  influences,  or  of  expo- 
sure to  the  poisonous  effects  of  certain  substances,  as  of  lead.  To 
particularize  the  numerous  conditions  which  furnish  illustrations  of 
each  of  these  different  causes  would  serve  no  useful  purpose.  A  few 
only  need  be  specially  noticed. 

We  •  have  often  to  treat  constipation  in  those  who  are  dyspeptic 
and  suffer  from  piles.  In  them  there  is,  in  all  probability,  some  con- 
gestion of  the  portal  system,  and  not  infrequently  a  constant  derange- 
ment of  the  flow  of  blood  through  the  liver.  The  normal  secretion 
of  intestinal  juices  is  interfered  with,  healthy  bile  is  not  supplied,  and 
costiveness  results.  A  similar  congestion  of  the  intestinal  mucous 
membrane  has  its  share  in  producing  the  constipation  which  is  en- 
countered in  disease  of  the  heart.  Sometimes,  however,  enough 
healthy  fluid  is  poured  out  within  the  intestine  ;  but  the  inclination 
to  go  to  stool  is  resisted,  and  the  liquid  that  has  been  mixed  with  the 
matter  to  be  voided  is  reabsorbed. 

The  influence  of  the  nervous  system  on  the  alimentary  tube  is 
shown  by  the  confined  state  of  the  bowels  which  attends  excessive 
intellectual  exertion  and  violent  emotions.  And  when  these  states 
are  protracted,  they  lead  to  a  permanent  and  annoying  debility  of  the 
intestine.  The  colon  especially  becomes  torpid  in  its  action,  and  all 
the  evil  results  of  constipation  show  themselves  in  the  most  marked 
degree.     Not  that  an  atony  of"  the  bowel  is  always  due  to  psychical 

^  In  the  American  Journal  of  the  Medical  Sciences,  Oct.  1874,  a  case  is  reported 
in  which  the  constipation  lasted  eight  months  and  sixteen  days. 


552  MEDICAL  DIAGNOSIS. 

agencies.  Any  disorder  which  induces  loss  of  power  in  the  muscu- 
lar fibres  may  give  rise  to  it.  We  And  it  in  ansemic  persons  and 
in  those  who  lead,  so  far  as  bodily  exertion  is  concerned,  a  sluggish 
life.  In  some  cases — fortunately  rare — the  weak  intestine  distends 
greatly,  and  becoming  unable  to  propel  the  accumulated  faeces,  in- 
superable constipation  occurs.  The  same  complete  paralysis  of  the 
tube  may  be  brought  about  by  chronic  lesions  of  the  brain  or  spinal 
cord. 

Among  the  different  organic  changes  in  the  intestine  which,  by  in- 
terfering mechanically  with  the  peristaltic  wave,  set  up  constipation,  we 
find  distention  of  the  tube,  with  atrophy  of  the  muscular  fibres ;  va- 
rious infiltrations  into  the  walls,  producing  a  narrowing  of  the  caliber, 
as  in  carcinoma ;  and  adhesions  between  the  serous  coats  of  the  in- 
testines, or  between  these  viscera  and  the  parietes.  Of  the  first,  it 
need  only  be  said  that  the  symptoms  are  due  to  the  same  paralyzed 
condition  of  the  intestine,  whether  complete  or  incomplete,  which 
has  been  already  considered,  and  which  is  recognized,  so  far  as  it 
can  be  recognized,  by  the  history  of  the  case.  The  second  group 
embraces  those  infiltrations  which  result  from  inflammations,  and 
new  growths  of  different  kinds  which  lead  to  strictures,  and  then 
the  peculiarities  in  the  form  and  size  of  the  faeces,  the  gradual  wasting 
and  exhaustion,  and  the  extreme  costiveness,  deepening  gradually 
into  invincible  constipation,  furnish  a  key  to  the  grievous  nature  of 
the  affection. 

When  the  constipation  arises  as  the  result  of  peritoneal  adhesions, 
there  are  sometimes  signs  in  the  case — such  as  tenderness  at  a  par- 
ticular spot  from  stin  existing  inflammation,  or  partial  distention  or 
retraction  of  the  abdomen — which  point  out  its  nature.  In  the  ab- 
sence of  these,  the  history  is  our  only  guide,  except  in  those  instances 
in  which,  as  Bright^  first  informed  us,  a  peculiar  sensation  is  commu- 
nicated to  the  touch,  varying  between  the  crepitation  produced  by 
emphysema  and  the  feel  derived  from  bending  new  leather  in  the 
hand. 

From  long-standing  constipation  stercoral  ulcers  may  arise.  The 
sacculi  of  the  colon  are  filled  with  little,  hard,  fecal  balls,  which  irritate 
the  mucous  membrane  and  produce  ulceration.  Mucus,  or  muco- 
pus,  with  stains  of  blood,  is  occasionally  discharged  with  the  small 
scybala,  and  at  times  there  is  diarrhoea. 


1  Cases  Illustrative  of  the  Diagnosis  of  Adhesions  and  other  Morbid  Changes 
of  the  Peritoneum,  Med.-Chir.  Transact.,  vol.  xix. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       553 

Disorders   in  -which   Morbid   Discharges   from   the   Bo^wels 

occur. 

Matters  very  unlike  the  healthy  alvine  evacuations  are  often  voided 
from  the  intestinal  canal :  loose  watery  stools,  large  quantities  of 
mucus,  pus,  or  blood,  may  be  discharged.  The  disorders  which 
occasion  these  discharges  may  be  here  described. 

Diarrhoea. — Like  constipation,  diarrlicea  will  be  merely  treated  of 
as  we  meet  with  it  constituting  the  entire  ailment,  or  at  all  events  its 
most  prominent  symptom.  There  are  several  varieties  of  diarrhoea. 
Difference  in  time  gives  rise  to  marked  varieties, — to  an  acute  and  to 
a  chronic  form ;  and  of  both  it  has  been  already  pointed  out  how 
often  the  lesion  is  an  intestinal  catarrh. 

Acute  Diarrhoea. — Acute  diarrhoea  proceeds  from  more  than  one 
cause  :  it  may  be  excited  by  the  irritating  character  of  the  food  taken, 
or  by  impure  water ;  it  may  be  brought  about  by  the  morbid  nature 
of  the  secretions  poured  into  the  intestines ;  it  may  be  owing  to 
atmospheric  influences, — to  heat,  to  moisture,  to  contaminated  air ;  it 
may  be  caused  by  chilhng  of  the  surface  of  the  body,  or  by  irritant 
poisons,  retained  faeces,  or  worms.  It  may  be  occasioned  by  pyaemia 
and  septicaemia,  by  reflex  irritation,  as  in  dentition,  or  by  mental 
emotions,  and  especially  by  fear.  Sometimes  it  occurs  in  an  epidemic 
form  due  to  some  unknown  miasm.  Its  symptoms  are  thirst ;  abdom- 
inal uneasiness  ;  griping  pain  in  the  bowel ;  pallor ;  slight  debility  ;  and 
frequent  fluid  alvine  evacuations,  which  may  finally  become  almost 
colorless. 

In  the  diarrhoea  caused  by  a  debauch  or  by  indigestible  food, 
nausea  and  a  furred  tongue  are  added  to  the  list  of  symptoms  men- 
tioned. This  kind  of  diarrhoea  is  generally  of  short  duration.  It  is 
an  effort  of  nature  to  get  rid  of  obnoxious  matter ;  and  when  this  is 
effected,  the  looseness  of  the  bowels  ceases. 

The  variety  of  diarrhoea  under  consideration  sometimes  goes  hand 
in  hand  with  a  disturbance  of  the  biliary  functions,  and  the  stools 
discharged  are  fetid,  and  present  the  appearance  generally  described 
as  bilious.  This  "  bilious  diarrhoea,"  too,  is  not  uncommon  in  persons 
whose  livers  are  habitually  sluggish.  It  is  also  frequently  encountered 
during  the  hot  months  of  summer  and  early  in  the  autumn,  and  has 
a  tendency  to  run  on. 

There  are  cases  of  diarrhoea  attended  witli  pain,  considerable 
soreness  to  the  touch,  and,  what  is  not  ordinarily  met  with  in  diar- 
rhoea, some  febrile  disturbance.  These  kinds  of  acute  diarrhoea,  or 
rather  of  acute  intestinal  catarrh,  or  of  muco-enteritis  with  diarrhoea 


554  MEDICAL  DIAGNOSIS. 

as  a  symptom,  are  often  the  consequence  of  irritant  poisoning,  or  are 
common  as  the  result  of  the  influence  of  cold,  or  of  acid  drinks  and 
unripe  fruit.  They  are  also  observ^ed  as  secondan^  disorders  in  the 
exanthemata. 

Chronic  Diarrhoea. — In  chronic  diarrhoea  the  lesions  encountered 
are  much  more  marked  than  they  ever  are  in  the  acute  form.  The 
mucous  membrane  is  tumid  and  discolored  ;  its  follicles  are  not  infre- 
quently ulcerated.  Chronic  looseness  of  the  bowels  originates  in  a 
diarrhoea  which  is  permitted  to  continue,  either  from  neglect  or  be- 
cause the  patient  remains  for  a  long  time  exposed  to  the  origmal  cause. 
The  disorder  is  apt  to  prove  rebellious.  When  of  long  standing,  the 
patient  becomes  gradually  weaker  and  weaker,  and  more  and  more 
emaciated.  The  abdomen  is  sunken  ;  the  complexion  is  pale  ;  the 
eyes  are  surrounded  by  a  leaden  ring.  The  character  of  the  discharges 
is  various.  They  are  often  dark-colored  and  very  offensive.  The  irri- 
tability of  the  intestines  never  intermits. 

Perhaps  the  most  persistent  irritability  of  the  intestines  is  found 
in  the  diarrhcea  to  which  soldiers  are  so  liable,  and  which  is  apt  to 
pass,  no  matter  what  its  beginning,  into  the  chronic  form  of  the  dis- 
ease. This  complaint,  which  follows  impure  water,  defective  diet, 
exposure,  malaria,  and  scurvy,^  which  is  generally  associated  with  a 
morbid  state  of  the  large  as  well  as  of  the  small  intestine,  and  which 
combines  therefore  some  of  the  features  of  chronic  dysentery  v^ath 
those  of  chronic  diarrhoea,  is  one  that  often  clings  to  its  victim  through 
life :  many  a  soldier,  in  truth,  escapes  the  bullet  and  the  sword,  only 
to  die  of  the  intestinal  affection  long  after  his  return  to  his  home. 

But  chronic  diarrhoea,  as  the  practitioner  of  medicine  commonly 
sees  it,  is  often  attendant  on  general  constitutional  affections,  or  on 
abdominal  diseases  that  have  led  to  a  secondary  disorder  of  the  secre- 
tions, or  even  of  the  coats  of  the  intestine.  Thus,  we  find  chronic 
looseness  of  the  bowels  in  scurvy,  in  pyaemia,  in  Bright's  disease,  in 
scrofula  of  the  mesenteric  glands,  and  hi  tuberculosis.  In  the  last  of 
these  complaints  the  charrhoea  may  be  occasioned  by  changes  in  the 
secretions  of  the  intestinal  glands;  but  it  is  not  seldom  dependent 
upon  a  true  tubercular  disease  of  the  intestines,  which,  like  the  disease 
of  the  lung,  leads  to  softening  and  ulceration.  The  discharges  are 
generally  copious  and  very  offensive,  and  show  traces  of  blood.  The 
diarrhoea  is  continuous  and  intractable  ;  the  abdomen  is  retracted,  and 


1  Woodward,  Outlines  of  the  Chief  Camp  Diseases,  p.  253  ;  see  also  the  elab- 
orate analysis  of  the  alvine  fluxes  in  vol.  ii.  of  the  splendid  "Medical  and  Surgical 
History  of  the  AVar  of  the  Rebellion,"  Washington,  1879. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.        555 

presents  spots  very  tender  to  the  touch.  There  are  marked  fever  and 
emaciation,  and  there  may  be  severe  intestinal  hemorrhage.  Yet, 
after  all,  only  the  signs  of  tubercle  elsewhere  furnish  any  positive  in- 
dications by  which  the  true  nature  of  the  wasting  malady  can  be  dis- 
cerned. Indeed,  it  may  happen  that  the  reverse  of  diarrhoea  occurs  ; 
for  acute  primar}^  miliary  tuberculosis  may  simulate  an  acute  intestinal 
obstruction.^  In  all  cases  of  suspected  tulDercular  diarrhoea  the  stools 
should  be  examined  for  tubercle  bacilli,  and  these  will  be  found  very 
generally. 

Tubercular  ulceration  is  the  most  prominent  type  of  ulcerative 
enteritis.  But  ulceration  of  the  bowel  is  also  met  with  under  other 
circumstances.  We  find  it  in  the  diarrhoeas  of  children ;  it  occurs 
then  diS,  follicular  ulceration.  Ulceration  is  also  occasionally  observed 
from  cancer,  or  as  a  solitary  ulcer  leading  to  perforation.  The  seat  of 
the  latter  is  generally  the  caecum  or  colon.  Albuminuric  ulceration, 
the  careful  analysis  of  Dickinson^  shows,  is  almost  invariably  asso- 
ciated with  contracted  kidney.  Simple  ulcerative  colitis  is  usually  met 
with  in  middle-aged  persons.  It  lasts  generally  about  two  months,^ 
and  is  ushered  in  by  abdominal  pain,  which  remains  a  symptom. 
There  is  diarrhoea  with  very  thin  movements,  but  there  are  no  dysen- 
teric stools  ;  blood  in  the  discharges  is  common.  The  diarrhoea  may 
alternate  with  attacks  of  constipation ;  often  there  is  vomiting.  The 
chsease  may  lead  to  perforation.  Unhealed  typhoid  idcers  form  another 
variety  of  ulceration  of  the  bowels. 

In  the  diagnosis  of  all  forms  of  intestinal  irritation,  we  njust  lay 
stress  on  the  diarrhoea,  on  the  character  af  the  discharges,  on  the 
pain,  and  on  the  occurrence  of  hemorrhage  from  the  bowels.  In  the 
discharges,  mucus  and  pus  and  shreds  of  tissue  are  valuable  signs. 
In  follicular  ulceration  little  sago-like  masses  of  mucus  are  met  with. 
The  stools  may  be  very  frequent ;  this  is  especially  the  case  if  the 
ulcer  be  in  the  lower  part  of  the  colon.  Abdominal  jDain  may  or  may 
not  be  associated  with  tenderness.  Pain,  as  in  other  forms  of  colitis, 
is  often  referred  to  the  prsecordial  region.  With  reference  to  the 
frequency  of  this,  Potain*  tells  us  that,  of  one  hundred  persons 
complaining  of  heart  disease,  about  seventy  have  an  affection  of  the 
colon. 

In  the  chronic  diarrhoea  of  strumous  children  there  is  sometimes  a 


1  Thoman,  Allg.  Wien.  Med.  Zeit.,  1887. 

^  Med. -Chirurg.  Trans.,  vol.  Ixxvii.,  1894. 

*-Hale  White,  Guy's  Hosp.  Reports,  3d  Series,  vol.  xxx. 

*  L'Union  Medicale,  Nov.  1894. 


556  MEDICAL  DIAGNOSIS. 

scrofulous  infiltration  into  the  intestinal  walls,  sometimes  marked 
scrofulous  enlargement  of  the  mesenteric  glands,  sometimes  both,  but 
in  some  cases  neither.  Improper  nourishment  may  be  here,  as  in 
any  other  form  of  the  diarrhoea  of  childhood,  the  exciting  cause  of 
the  continued  purging. 

At  times  chronic  diarrhoea  assumes  an  intermittent  type,  and  its 
malarial  nature  is  clearly  proved  by  the  readiness  with  which  the 
disorder  yields  to  quinine.^  In  this  respect  malarial  diarrhoea  differs 
from  a  form  of  diarrhoea  we  sometimes  encounter,  in  which  the  pain 
and  discharges  come  on  at  an  early  hour  of  the  day  and  cease  towards 
evening  and  during  the  night. 

Another  form  of  looseness  of  the  bowels  is  the  membranous.  Here 
the  discharges  show  shreds  of  membrane,  either  in  connection  with 
the  loose  stools,  or  sometimes  in  such  quantities  that  the  whole  mass 
voided  seems  to  consist  of  them.  Griping  pains  and  tenderness 
usually  precede  this  kind  of  diarrhoea,  which  may  happen  in  attacks 
of  a  subacute  form,  or  as  a  persistent  and  very  obstinate  disorder : 
the  former  variety  is  the  more  common.  The  fecal  discharges  are 
loose,  but  occasionally  there  is  constipation.  The  disease  is  often 
associated  with  peculiar  hysterical  symptoms  or  occurs  in  neuras- 
thenics. The  so-called  membranes,  in  this  membranous  enteritis, 
contain  a  large  amount  of  mucus,  as  I  have  elsewhere  described.^ 

Dysentery. — Frequent  and  painful  passages  of  mucus  mixed  with 
blood,  accompanied  by  straining  and  bearing  down,  are  the  charac- 
teristic symptoms  of  dysentery.  In  the  acute  form  we  find  thirst, 
restlessness,  and  fever  superadded ;  and  sometimes,  especially  when 
the  disease  prevails  epidemically,  those  symptoms  of  prostration 
which  are  commonly  designated  as  typhoid. 

Acute  Dysentery. — The  acute  disorder  is  at  times  ushered  in  by  a 
chill ;  at  times  it  is  preceded  by  diarrhoea.  The  fever  which  attends 
it  is  not  generally  intense.  It  is  the  exception  to  find  it  exceed  103°, 
and  in  light  cases  the  temperature  is  only  slightly  raised ;  the  pulse 
is  not  tense.  More  or  less  pain  is  always  present ;  it  has  its  seat 
mostly  at  some  part  of  the  colon,  and  this  is  tender  on  pressure.  It 
is  intermitting  and  shifting,  and  is  often  accompanied  by  a  feeling  of 
weight  near  the  anus,  which  causes  a  continual  desire  to  go  to  stool. 
Yet  no  relief  follows  the  frequent  attempts  ;  the  violent  straining  only 
adds  to  the  discomfort. 


1  See  contribution  by  Sanford  B.   Hunt  on  Diarrhcea,  in  Medical  Memoirs  of 
the  U.  S.  Sanitary  Commission,  p.  306. 

^  American  Journal  of  the  Medical  Sciences,  Oct.  1871. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       557 

The  matters  voided  are  small  in  quantity.  They  consist  of  blood 
mixed  with  mucus ;  yet  they  are  composed  not  simply  of  mucus,  but 
also  of  leucocytes,  granules,  and  large  quantities  of  cast-olf  epithe- 
lium, with  many  swollen,  round  or  ovoid  epithelial  cells.  The  stools 
are  in  some  cases  highly  offensive,  and  resemble  the  washings  of 
meat :  in  others  they  are  like  jelly,  or  greenish  in  color.  They  do 
not  contain  faeces,  or  only  here  and  there  small,  firm  lumps  of  fecal 
matter.  When  the  dysenteric  inflammation  subsides,  the  bowels  are 
unloaded  of  their  contents ;  in  consequence,  the  passage  of  quantities 
of  small,  hard  masses  of  faeces  is  generally  a  sign  that  the  acute 
malady  is  inclining  to  a  favorable  termination.  Sometimes  the  stools 
are  very  dark  and  slimy  and  have  a  putrid  odor,  and  here  and  there 
pieces  of  sloughed-off  tissue  can  be  detected.  This  kind  of  stool 
marks  the  diphtheritic  or  gangrenous  variety  of  the  malady,  though 
it  is  not  constant  even  in  this. 

How  long  it  will  take  for  the  disorder  to  run  its  course,  or  whether 
the  acute  disease  will  pass  into  chronic  dysentery,  cannot  be  fore- 
told. Generally  this  is  not  its  termination  ;  it  very  often  ends,  within 
a  week  from  its  beginning,  in  recovery.  But  severe  cases  occur 
which  are  of  much  shorter  duration,  in  which  the  symptoms  hasten 
on  to  complete  prostration,  and  death  takes  place  early  in  the  malady. 
In  these  frightful  cases — mostly  epidemic — collapse  may  happen  with 
almost  the  same  rapidity  as  it  does  in  malignant  cholera. 

Dysentery  is  essentially  a  disease  of  hot  climates.  Eating  green 
fruits,  exposure  to  a  chilly  night  after  a  hot  day,  and  sleeping  on  damp 
ground,  are  prolific  exciting  causes.  It  is  occasionally  found  in  com- 
bination with  malarial  fevers,  or  with  scurvy.  It  also  occurs  from 
drinking  water  full  of  impure  substances  or  micro-organisms,  and  is 
thought  to  have  a  bacillus  of  its  own.  It  may  be  seen  in  a  sporadic 
or  in  an  epidemic  form.  It  is  very  common  in  armies  and  in  jails. 
The  immediate  cause  of  most  of  the  symptoms  is  inflammation  of  the 
large  intestine,  and  especially  of  the  descending  colon.  Yet  in  many 
cases  of  dysentery  we  see  phenomena  manifested  which  are  clearly 
not  to  be  accounted  for  solely  by  the  local  morbid  appearances,  and 
which  show  that  dysentery  mostly  belongs  to  the  infectious  maladies. 
In  truth,  inflammation  of  the  colon  may  give  rise  to  the  symptoms 
of  acute  diarrhoea ;  for  it  is  a  great  mistake  to  suppose  that  the  cause 
of  diarrhoea  is  to  be  sought  only  in  some  abnormal  change  in  the 
small  intestines.  Thus,  colitis  is  not  always  dysentery  ;  and  dysen- 
tery is  often  more  than  mere  colitis. 

But,  whatever  be  the  ultimate  cause  or  the  form  of  dysentery,  we 
find  that  it  presents  peculiarities  which  render  it  easy  of  recognition 

35 


558  MEDICAL  DIAGNOSIS. 

at  the  bedside.  Yet  we  must  take  good  care  to  ascertain  that  the 
supposed  characteristic  tenesmus  and  bloody  discharges  are  not  really 
owing  to  piles,  or  to  morbid,  especially  cancerous,  gro^vths  in  the 
rectum,  or  to  ordinary  limited  inflammation  there.  In  the  latter 
case,  or  proctitis,  there  is  much  pain  when  the  hardened  faeces  are 
discharged,  the  rectum  is  forced  down  during  the  efforts,  the  sphinc- 
ter contracts  spasmodically.  Strangury  and  hemorrhoids  are  not 
uncommon  symptoms  ;  and,  as  the  consequence  of  the  inflammation 
extending  to  the  parts  around  the  anus,  an  abscess  may  follow. 
Rectal  pain  often  e^f tends  to  the  thighs. 

Dysentery  is  not  apt  to  be  confounded  with  diarrhoea.  This  dif- 
fers essentially  from  dysentery  by  the  liquid  fecal  evacuations,  and  by 
the  fact  that  neither  tenesmus,  nor  bloody  stools,  nor  discharges  of 
mucus  occur.  Yet  in  practice  we  meet  with  cases  which  begin  mth 
diarrhoea  and  terminate  in  dysentery,  or  begin  mth  dysenteric  symp- 
toms and  terminate  in  diarrhoea,  and  in  which  it  becomes,  therefore, 
puzzling  to  say  which  disorder  we  are  dealing  with. 

There  are  some  clinical  varieties  of  dysentery  which  it  is  impor- 
tant to  separate.  The  ordinary  form  seen  in  temperate  climates  to 
follow  errors  in  diet  or  exposure  is  the  catarrhal  form.  In  tropical 
climates,  where  dysentery  is  very  common  and  is  met  with  frequently 
as  an  epidemic,  we  find  mostly  a  kind  that  is  characterized  by  the 
presence  of  the  amoeba  coli,  or  amoeba  dysenterice,  as  Councilman  and 
Lafleur^  call  the  micro-organism.  Amoebie  dysentery  does  not,  as  a 
rule,  run  so  rapid  a  course  as  ordinary  catarrhal  dysentery,  and  local 
tissue  degenerations  in  the  liver,  or  abscesses  of  the  liver,  are  com- 
mon attendants.  The  abscesses,  like  the  discharges  from  the  bowels, 
contain  amoebse.  The  evacuations,  as  the  disease  progresses,  lose 
their  dysenteric  characteristics,  except  the  mucus,  and  become  very 
liquid ;  the  tenesmus  disappears.  The  amoebge  are  most  active  in 
alkaline  stools.  The  diarrhoea  has  marked  exacerbations  and  remis- 
sions, and  is  attended  by  striking  anaemia.  The  fever  is  very  mod- 
erate. In  some  instances  hemorrhage  from  the  bowels,  in  others 
peritonitis,  happens.  It  is  not  unusual  in  protracted  cases  for  the 
urine  to  become  albuminous  and  to  contain  casts. 

In  tropical  climates,  too,  though  also  seen  elsewhere  in  persons 
who  have  low  forms  of  pneumonia,  or  who  have  become  cachectic 
from  scurvy,  from  Bright's  disease,  or  from  long-standing  disease  of 
the  heart,  a  form  of  dysentery  attended  by  extensive  exudation  and 
sloughing  of  the  membranes  is  met  with.     The  diphtheritic  dysentery, 

^  Johns  Hopkins  Hospital  Reports,  vol.  ii. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       559 

as  it  is  called,  has  generally  high  fever,  much  abdominal  pain,  great 
prostration,  and  delirium.  The  discharges  are  very  frequent ;  the 
blood  gradually  disappears  from  them.  Vomiting,  especially  at  the 
onset,  is  common.  In  the  progress  of  the  case,  which  is  generally 
to  a  fatal  issue,  the  temperature  becomes  irregular,  and  hiccough  is 
not  uncommon. 

Chronic  Dysentery. — We  rarely  see  chronic  dysentery  without 
chronic  diarrhoea.  At  all  events,  we  seldom  find  instances  of  the 
former  in  which  the  tenesmus  and  the  discharge  of  blood  and  mucus 
mixed  with  pus  are  not  accompanied  by  frequent  loose  alvine  evacua- 
tions, by  griping,  by  the  same  gradual  wasting  and  the  same  irrita- 
bility of  the  bowels  as  are  encountered  in  chronic  diarrhoea ;  nay,  the 
symptoms  of  the  latter  may  so  obscure  the  true  nature  of  the  malady 
that  what  has  been  regarded  as  chronic  diarrhoea  turns  out,  at  the 
autopsy,  to  be  chronic  dysentery.  The  mucous  membrane  of  the 
colon  is  found  to  be  extensively  inflamed ;  its  texture  altered  and 
irregularly  thickened ;  its  surface  riddled  with  ulcers.  In  such  cases 
the  patient  goes  on  steadily  losing  Jflesh,  and  has  some  elevation  of 
temperature ;  but  no  pain  on  pressure  or  localized  distress  exists  to 
denote  the  ravages  the  disease  is  making  in  the  alimentary  tube. 
Many  die  from  exhaustion ;  others,  in  consequence  of  abscess  of  the 
liver,  which  chronic  as  well  as  acute  dysentery  may  induce. 

Intestinal  Hemorrhage,  or  Meleena. — This  is  commonly  the 
result  of  a  mechanical  hinderance  to  the  flow  of  blood  through  the 
liver,  as  in  cirrhosis,  or  of  disease  of  the  heart,  or  of  a  depraved  state 
of  the  blood, — such  as  exists  in  typhus  fever,  in  yellow  fever,  in  scurvy, 
or  in  purpura.  Occasionally  the  bleeding  proceeds  from  a  fungoid 
growth  in  the  intestine,  or  from  an  ulcer  in  the  duodenum  or  ileum, 
or  from  an  invagination,  or  from  fecal  impaction,  or  from  an  amyloid 
degeneration  of  the  mucous  membrane  of  the  bowel,  or  is  due  to 
a  disease  of  the  spleen,  or  to  bursting  of  an  aneurism,  or  follows 
extensive  burns  of  the  abdominal  parietes.  In  very  young  infants 
a  discharge  of  blood,  both  by  the  mouth  and  by  the  rectum,  is  not 
unusual. 

The  blood  passed  by  stool  is  generally  of  dark  color,  like  tar. 
When  it  is  not,  we  may  infer  that  it  flows  from  the  lower  part  of  the 
intestine  and  has  not  had  time  to  become  admixed  with  other  mat- 
ters. In  all  such  cases,  however,  we  must  make  sure  that  it  does 
not  proceed  from  hemorrhoids.  The  exact  seat  of  the  hemorrhage 
cannot  be  determined ;  nay,  blood  may  be  evacuated  by  the  bowel 
and  not  be  poured  out  at  all  from  the  intestine,  but  from  the  stomach. 
In    some  instances  the  blood  accumulates  in  the  bowel,  and,  before 


560  MEDICAL  DIAGNOSIS. 

the  clots  moulded  to  its  shape  are  discharged,  death  results.^  When 
the  bleeding  proceeds  from  hemorrhoids  it  is  seldom  vicarious.^ 

In  point  of  diagnosis  the  first  thing  to  determine  is,  that  what  is 
supposed  to  be  blood  is  really  blood.  Very  dark  bilious  stools,  or 
stools  blackened  by  iron,  may  mislead.  If  doubt  exist,  water  should 
be  poured  on  the  stool,  and,  when  blood  is  present,  a  reddish  tmge  is 
Imparted  to  the  water ;  yet  more  accurate  is  it  to  examine  with  the 
microscope  or  the  spectroscope. 

We  next  have  to  ascertain  the  disease  with  which  the  intestmal 
hemorrhage  is  associated ;  and  this  is  often  a  very  difficult  matter. 
We  must  lay  the  greatest  stress  on  the  history  of  the  case,  look  for 
the  complaints — of  which  most  have  been  above  mentioned — that  are 
apt  to  give  rise  to  the  bleeding,  especially  investigating  for  cirrhosis  of 
the  liver ;  searching  for  intestinal  ulcers  in  connection  with  typhoid 
fever,  or  tuberculosis,  or  a  duodenal  affection ;  or  examining  for  the 
€Addence  of  scurvy  in  the  gums  and  skin ;  or  for  purpura  with  its 
characteristic  spots  ;  or  for  splenic  enlargement,  the  result  of  chronic 
malaria  or  of  amyloid  degeneration.  Embolism  of  the  superior  mes- 
enteric artery  may  also  occasion  intestinal  hemorrhage.  But  unless 
Ave  have  Avith  the  bloody  stools  marked  abdominal  pains,  peritoneal 
exudation,  and  obAdous-causing  elements  of  embolism,  or  signs  of  it 
elseAvhere,  this  diagnosis  is  most  uncertain. 

Fatty  Diarrhoea. — In  some  cases  in  AA^hich  fatty  matter  is  voided 
by  the  bowel,  oil  is  at  the  same  time  passed  Avith  the  urine ;  in  others 
the  urinary  secretion  is  healthy ;  some  cases  end  fatally,  others  in  re- 
covery ;  some  are  found  to  be  connected  Avith  a  disease  of  the  pan- 
creas, others  are  not ;  in  some  the  disorder  is  not  of  long  continu- 
ance, Avhile  in  others  it  lasts,  with  intervals,  for  years.  As  a  rule, 
the  occurrence  of  fatty  stools  is  a  matter  of  serious  concern.  The 
recognition  of  the  malady  is  easy.  The  Avhite,  fatty  masses,  or  the 
oily  matter  Avhich  collects  on  the  discharges,  are  soluble  in  ether,  and 
are  readily  proved  to  be  fat  by  the  microscope.  In  some  instances 
the  boAvels  are  constipated,  and  lumps  of  hard  fasces  are  discharged 
along  Avith  the  fatty  substance.  This  happened  in  a  marked  example 
of  the  disorder  that  came  under  my  observation.  The  patient,  a  man 
of  tAventy-six  years  of  age,  passed  a  considerable  amount  of  fat,  both 
by  the  rectum  and  Avith  the  urine.  He  suffered  much  from  digestive 
disturbance,  from  constipation,  and  from  Aveakness.     He  had  a  good 

^  See  obsen'ations  of  Cheyne,   Dublin  Hospital  Reports,  vol.  i.,  and  of  Bel- 
combe,  Medical  Gazette,  vol.  iv. 
^  Lee  on  the  Rectum. 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       561 

api3etite,  but  a  dislike  to  fats  of  any  kind.  In  his  case  there  was,  as 
far  as  the  other  symptoms  and  the  physical  signs  indicated,  no  tumor 
in  the  region  of  the  pancreas.  The  man's  condition  was  much  im- 
proved by  careful  diet  and  the  administration  of  cinchona  and  rhu- 
barb ;  but  whether  permanently  or  not  I  cannot  say,  as  I  lost  sight  of 
him.  I  have  also  met  with  instances  of  fatty  diarrhoea  associated  with 
saccharine  diabetes  and  with  disease  of  the  pancreas.  In  examining 
into  the  subject  of  fatty  stools  it  must  be  borne  in  mind  that  the  clay- 
colored  stools  of  jaundice,  owing  to  the  absence  of  the  emulsifymg 
properties  of  the  bile,  contain  considerable  fat,  which  may  be  found  in 
oil-drops  or  as  fine  needle-shaped  fat-crystals. 

Diseases  attended  with  Vomiting  and  Purging. 

There  is  a  group  of  diseases  in  which  vomiting  and  purging  are 
very  prominent  symptoms.  The  most  important  of  these  are  the 
various  forms  of  cholera.  Now,  there  are  several  very  different  com- 
plaints classed  together  under  the  head  of  cholera. 

Cholera  Infantum. — And  first,  of  the  so-called  cholera  of  in- 
fants. It  is  an  endemic  in  the  larger  cities  of  the  United  States  during 
the  hot  months,  and  one  fraught  with  danger  to  all  young  children. 
It  begins  generally  with  diarrhoea.  Vomiting  soon  follows  ;  and  for  a 
time  the  two  go  hand  in  hand ;  but,  unless  the  case  be  of  short  dura- 
tion, the  spontaneous  vomiting  ceases,  or  at  all  events  gives  way  to 
occasional  exacerbations  of  irritability  of  the  stomach,  while  the 
looseness  of  the  bowels  remains,  or  even  augments.  The  discharges 
are  colorless,  or  yellowish,  or  greenish.  There  is  thirst ;  sometimes 
fever.  The  abdomen  may  be  sunken  or  swollen ;  and  it  may  be 
tender.  Sometimes  the  disease  runs  its  course  within  three  or  four 
days,  at  the  end  of  which  time  the  child  dies,  worn  out  by  the  con- 
stant vomiting  and  purging.  More  generally  the  disorder  is  of  longer 
duration ;  for  weeks  or  for  months  it  continues,  the  diarrhoea  im- 
proving and  then  returning  with  redoubled  severity,  and  kept  up  or 
increased  by  the  irritation  of  teething.  The  irritability  of  the  intes- 
tinal canal,  and  the  utter  impossibility  of  retaining  enough  food  to 
nourish  the  wasting  body,  gradually  wear  out  the  system.  The  child 
before  dfeath  is  wan  and  distressingly  emiaciated  ;  sometimes  hypo- 
static congestion  of  the  lungs,  broncho-pneumonia,  boils,  suppression 
of  urine,  plaintive  cries,  rolling  of  the  head,  strabismus,  and  coma 
precede  the  fatal  termination. 

Such  is  a  sketch  of  grave  and  intractable  cases.  Yet  very  many 
cases  are  far  from   being   desperate.     Under  judicious   treatment  a 


562  MEDICAL  DIAGNOSIS. 

large  number  are  annually  saved.  Recoveries  would  bear  a  still 
liigher  proportion  to  the  deaths  were  it  not  that  the  greatest  sufferers 
from  the  disease,  the  cliildren  of  the  poor,  are  unable  to  obtain  the 
means  most  certam  to  restore  them  to  health, — change  of  air.  Cooped 
up  in  crowded  neighborhoods,  surrounded  on  all  sides  by  filth  rapidly 
decomposing  under  the  burning  rays  of  the  sun,  they  are  compelled 
to  breathe  the  hot,  noxious  atmosphere  which,  if  it  do  not  produce, 
is  certainly  a  decided  agent  in  keeping  up,  the  complaint. 

The  disease  is  an  entero-colitis  from  milk-infection  leading  to  bac- 
terial fermentation  in  the  intestines,  with  enlargement  of  the  solitary 
glands,  and  even  at  tunes  of  Peyer's  patches.  The  researches  of 
Vaughan  have  demonstrated  that  a  ptomaine  appearing  in  milk,  tyro- 
toxicon,  is  its  most  frequent  source.  Temporary  diarrhoeas  in  chil- 
dren occurring  in  hot  weather  could  alone  be  mistaken  for  the  dis- 
order. But  the  fact  that  they  are  temporary,  not  followed  by  vomiting, 
and  not  associated  with  the  grave  symptoms  of  approaching  collapse, 
shows  us  the  difference. 

Cholera  Morbus. — This,  or  cholera  nostras,  is,  like  cholera  infan- 
tum, a  disease  of  the  hot  season  ;  yet  it  is  also  observed  at  other 
times  of  the  year.  But,  although  the  chief  predisposing  cause  is 
undoubtedly  heat,  there  is  generally  an  exciting  cause  which  develops 
the  disorder, — such  as  exposure,  checked  perspiration,  drinking  large 
quanties  of  ice-water,  or  imprudence  in  eating.  The  attack  is  char- 
acterized by  spasmodic  pains  in  the  abdomen,  by  cramps  in  the  legs, 
by  rapid  loss  of  strength,  and  by  repeated  vomiting  and  purging. 
The  matter  ejected  both  from  the  stomach  and  from  the  intestines  is 
liquid,  and  contains  a  large  quantity  of  bile.  In  truth,  the  affection  is 
in  reality  a  cholera,  a  flow  of  bile,  which  its  more  formidable  name- 
sake, Asiatic  cholera,  is  not.  Finkler  and  Prior  have  found  in  the 
stools  a  comma  bacillus,  vibrio  j^roteiis,  which  is  larger  and  tliicker 
than  the  bacillus  of  Asiatic  cholera,  but  with  shorter  spirilla,  and  cul- 
tures of  which,  unlike  the  latter,  rapidly  liquefy  in  gelatin,  and  grow 
on  potato  even  at  ordinary  temperatures. 

Cholera  morbus  may  be  preceded  by  colicky  pains,  nausea,  and 
rumbling  in  the  intestmes.  More  generally  it  comes  on  suddenly. 
When  at  its  height,  the  cramps  in  the  calves  of  the  legs  cause  the 
muscles  to  rise  up  in  hard,  knotty  masses  ;  the  stools  are  fetid ;  the 
vomiting  is  constant ;  the  thirst  is  great,  and  the  skm  is  cool  or  cold. 
But  the  patient  does  not  remain  long  in  this  condition.  In  the  course 
of  a  few  hours,  or  at  the  utmost  of  a  day,  the  symptoms  mitigate,  or 
yield  entirely  to  treatment ;  and,  pale  and  visibly  emaciated  though 
he  be,  he  speedily  regains  his  health.     Only  in  some  cases  the  disease 


DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.       563 

proves  intractable,  and,  after  running  on  for  several  days,  passes  into 
a  state  of  hopeless  collapse. 

There  are  not  many  morbid  states  with  which  cholera  morbus  is 
likely  to  be  confounded.  It  may  be  mistaken,  as  we  shall  presently 
see,  for  epidemic  cholera.  We  find  many  points  of  similarity  between 
it  and  irritant  poison ;  but  there  are  also  strong  points  of  difference. 
The  vomiting  and  purging  produced  by  an  irritant  poison  do  not  come 
on  at  the  same  time :  the  vomiting  precedes  the  purging,  and  there 
may  be  bloody  evacuations.  The  pain  is  first  in  the  epigastrium, 
thence  it  may  spread.  Moreover,  we  often  detect  signs  in  the  mouth 
or  fauces  which  prove  the  irritating  character  of  the  substance  swal- 
lowed. The  vomiting  and  the  subsequent  acute  gastritis  are  accom- 
panied by  fever,  which  is  not  the  case  in  cholera  morbus. 

Cholera. — The  formidable  complaint  known  as  epidemic  cholera, 
Asiatic  cholera,  malignant  cholera,  or  by  the  simple  name  of  cholera, 
has  some  strikiag  features  of  resemblance  to  the  disorder  just  consid- 
ered. It  shares  with  cholera  morbus  the  vomiting  and  purging,  the 
cramps,  the  sudden  depression  ;  but  it  is  an  affection  of  different  origin 
and  of  much  more  serious  import,  and  presents  symptoms  not  encoun- 
tered in  the  cholera  that  occurs  yearly  during  the  hot  weather.  And 
although,  on  account  of  the  gastric  and  intestinal  disturbances  which 
form  so  prominent  a  part  of  its  manifestations,  it  is  here  described 
among  the  disorders  of  the  alimentary  tube,  I  am  doing  so  for  the 
sake  of  clinical  convenience,  and  contrary  to  sound  pathology ;  for 
cholera  is  not  an  affection  either  of  the  stomach  or  of  the  intestines  ; 
it  is  an  epidemic  constitutional  disorder  of  the  most  formidable  char- 
acter generated  by  a  poison  transmitted  to  us  from  the  East.  The 
poison  leads  to  a  casting  off  of  the  epithelium  of  the  mucous  mem- 
brane of  the  alimentary  tube ;  perhaps  to  changes  in  the  membrane. 
But  the  engorged  veins  all  over  the  body  ;  the  exosmosis  of  the  watery 
parts  of  the  blood ;  the  frightfully  rapid  prostration ;  the  sudden  blight 
which  befalls  the  nervous  powers, — are  elements  which  are  even 
more  characteristic. 

The  access  of  cholera  is  at  times  sudden  and  most  unexpected; 
the  patient,  previously  in  good  health,  is  stricken  down  without 
warning  by  the  force  of  the  poison.  More  generally  there  is  a  pre- 
monitory stage :  a  stage  of  languor,  low  spirits,  uneasiness,  headache, 
and  diarrhoea.  The  effects  of  the  morbific  matter  are  indeed  visible 
in  hundreds  of  individuals  who,  during  the  prevalence  of  cholera, 
suffer  from  these  premonitory  symptoms  without  any  of  greater 
danger  arising.  Nay,  the  same  influences  which  give  rise  to  chol- 
eraic diarrhoea  in  healthy  persons  have  the  eff'ect  of  rendering  the 


564  MEDICAL  DIAGNOSIS. 

bowels  of  those  habitually  constipated  regular,  and  sometimes  even 
loose. 

When  the  malignant  disease  is  fairly  developed,  there  is  vomiting 
as  well  as  purging.  The  contents  of  the  stomach  and  intestines  are 
first  voided,  and  then  large  quantities  of  a  rather  turbid  fluid  resem- 
bling rice-water,  with  whitish  particles  like  rice  floating  in  it.  They 
are  the  epithelial  cells  of  the  alimentary  tube,  which  have  been 
thrown  off"  from  the  mucous  membrane ;  and  in  the  dejecta  we  find 
the  comma  bacillus  discovered  by  Koch.  This  may  be  seen  by 
examining  microscopically  the  bacilli  obtained  from  a  small  amount 

Fig.  55. 


The  comma  bacillus  of  Koch,  from  culture  in  blood-serum.    Zeiss  ^^  homo,  ira.,  Oc.  4. 

of  cholera  dejection  that  has  been  mixed  with  an  equal  amount  of 
alkaline  meat  broth  at  a  temperature  of  30°  to  40°  C.  and  allowed  to 
stand  for  twelve  hours  in  an  ope*n  glass.  The  cholera  bacilli  develop 
on  the  surface.  They  are  readily  stained,  in  about  ten  minutes,  with 
a  diluted  alcoholic  solution  of  fuchsin  or  methyl  violet.  They  are 
decolorized  by  Gram's  process.  After  the  staining,  which  must  take 
place  with  the  infected  side  downward,  the  cover-glasses  are  washed 
in  water,  dried  with  the  prepared  side  uppermost,  and  mounted  in 
Canada  balsam.  Prior  to  the  staining  a  drop  of  the  infected  broth  or  a 
particle  from  a  stool  is  dried  in  air,  after  having  been  rubbed  between 
two  cover-glasses  and  passed  three  times  through  the  flame  of  a  Bun- 


DISEASES  OF  THE   INTESTINES  AND  PERITONEUM.       565 

sen  burner.  The  bacilli  of  cholera  may  be  recognized  even  without 
the  microscope  by  a  rose-violet  color,  the  cholera  reaction^  that  becomes 
apparent  in  a  few  minutes  if  a  ten  per  cent,  hydrochloric  acid  solu- 
tion is  added  to  cholera  cultures.  The  cholera  bacillus  is  confined  tO' 
the  intestine.  In  the  extensive  observations  made  by  Shakespeare  in 
India  and  elsewhere  ^  it  was  not  detected  in  the  blood  or  in  the  tissues 
or  organs  outside  of  the  intestinal  canal.  The  cholera  toxine  derived 
from  the  bacilli  has  been  specially  studied  by  Pfeiffer. 

Simultaneously  with  the  vomiting  and  purging,  or  very  shortly 
after,  come  on  severe  spasmodic  pains  in  the  abdomen,  and  cramps  of 
the  muscles  of  the  belly  and  of  the  extremities.  With  all  this  there 
are  a  burning  sensation  in  the  epigastric  region ;  an  unquenchable 
desire  for  cold  drinks  ;  a  cool  skin  ;  a  pulse  slightly  more  frecjuent  than 
normal ;  a  temperature  which  may  be  normal  or  may  fall  to  about 
95°  F. ;  oppressed  breathing ;  and  rapidly  progressing  exhaustion. 
The  case  now  stands  on  the  verge  of  collapse.  Should  this  follow,. 
the  pulse  becomes  hardly  perceptible.  The  discharges  cease,  and  so 
do  often  the  cramps.  The  skin  is  cold,  covered  with  a  clammy  sweaty 
and  has  a  bluish  look.  The  nails  and  the  lips  have  the  same  un- 
natural appearance.  The  whole  body  shrinks,  and  seems  at  times, 
almost  to  wither  visibly  even  while  under  inspection.  The  counte- 
nance assumes  the  aspect  of  death  ;  the  eyes  are  sunken  and  have  a 
glassy  look.  The  temperature  is  low,  it  may  fall  below  90°  ;  but 
while  very  low  in  the  mouth  or  axilla,  it  may  be  103°  or  more  in  the 
rectum.  The  intellect  is  commonly  clear;  but,  Avhen  the  patient 
talks,  the  words  fall  strangely  on  the  ear.  It  seems  as  if  a  corpse 
had  spoken,  and  the  voice  is  husky  and  faint.  The  tongue  and  the 
expired  air  are  cold.  No  symptom,  indeed,  has  struck  me  more 
forcibly  than  the  icy  breath. 

But  the  symptoms  do  not  ahvays  take  place  in  the  order  described, 
nor  are  they  all  uniformly  present.  The  vomiting  and  purging  may 
be  wanting  from  the  onset,  and  so  too  may  the  cramps.  Only  one 
symptom  is  never  absent, — the  tendency  to  early  sinking.  Sometimes 
a  stage  of  perfect  collapse  is  reached  with  frightful  rapidity :  instead, 
as  is  commonly  the  case,  of  several  hours  elapsing  before  complete 
prostration  comes  on,  the  vital  powers  are  at  once  laid  low  by  the 
assault  of  the  dreadful  malady.  When  cholera  last  prevailed  in  Philfi- 
delphia,  I  attended  a  woman  who,  at  six  o'clock  in  the  morning, 
was  in  perfect  health,  and  who,  in  a  little  more  than  half  an  hour 
afterwards,  was  lifeless.     There  was  neither  vomiting  nor  purging; 

^  Report  on  Cholera  in  Europe  and  Asia,  Washington,  1890. 


566  MEDICAL  DIAGNOSIS. 

nothing  but  cramps,  stupor,  and  speedy  collapse.  Such  cases  are  not 
uncommon  in  the  home  of  cholera, — India.  Post-mortem  inspection 
shows  the  thin  rice-water  fluid  locked  up  in  the  alimentary  canal. 
Nature  makes  an  effort  to  eliminate  the  poison ;  but  before  she  com- 
pletes her  task,  life  is  palsied. 

In  those  cases  that  recover,  or  in  those  of  light  character,  chol- 
erine, the  vomiting  and  purging  gradually  subside,  the  skin  becomes 
warm,  the  pulse  fuller,  the  abdominal  pain  ceases,  the  urine — which, 
while  the  disease  is  at  its  height,  is  not  passed,  perhaps  not  se- 
creted— is  again  voided,  the  patient  falls  into  a  refreshing  sleep,  and, 
the  symptom  most  favorable  of  all,  bile  reappears  in  the  stools. 
Even  in  apparently  hopeless  cases  of  collapse  we  may  be  fortunate 
enough  to  witness  these  favorable  changes.  But,  where  the  prostra- 
tion has  been  great,  the  reaction  is  apt  to  be  violent.  A  decided 
fever  of  low  type,  with  rapid  pulse  and  heat  of  skin,  and  attended 
very  often  by  alarming  cerebral  symptoms,  succeeds  ;  and  the  urinary 
secretion,  even  if  it  had  been  restored,  becomes  again  very  scanty. 
Thus  the  period  of  reaction  brings  with  it  new  dangers,  and  of  a 
kind  which  are  sometimes  insurmountable.  And  this  low  form  of 
fever,  very  similar  to  typhoid,  though  readily  enough  distinguished  by 
the  preceding  symptoms,  may  last  for  upward  of  a  week  before 
death  takes  place  or  the  signs  of  danger  gradually  yield.  Now,  this 
cholera  typhoid  may  be  preceded  by  scanty  urine  and  marked  uraemia, 
but  it  may  also  exist  independently  of  this  morbid  state,  though  prob- 
ably also  due  to  the  blood  being  loaded  with  broken-down  material. 
In  cases  in  which  uraemia  sets  in,  whether  it  be  followed  or  not  by  a 
fever  of  low  type,  there  is  at  first  but  little,  if  any,  heat  of  skin,  and 
a  slow  pulse  ;  the  patient  is  wild,  restless,  or  drowsy ;  the  kidneys  act 
very  imperfectly,  the  urine  is  greatly  deficient  in  urea,  and  usually 
contains  albumin.  These  are  very  dangerous  cases,  and  if  the  secre- 
tion be  seriously  retarded  for  more  than  twenty-four  hours  they  are 
likely  to  perish.  Other  complications  that  may  arise  are  pneumonia, 
pleurisy,  suppurative  parotitis,  and  protracted  nephritis. 

In  any  case  of  cholera,  convalescence  is  apt  to  be  slow.  For 
weeks  or  months  irritability  of  the  intestinal  canal  remains ;  and  I 
have  met  with  instances  in  which  it  has  never  disappeared.  In  con- 
valescence, too,  we  may  find  constantly  recurring  cramps  in  the  arms 
and  legs. 

It  would  be  needless  to  go  into  any  minute  description  of  the  dif- 
ferences between  cholera  and  other  affections ;  its  features  are  not  to 
be  mistaken.  Cholera  morbus  is  the  only  disorder  which  really  re- 
sembles it.     The  dividing-line  is  drawn  by  the  absence  of  bile  in  the 


DISEASES  OF  THE  LIVER.  567 

discharges,  the  rice-water  evacuations,  the  greater  severity  and  more 
rapid  progress  of  tlie  symptoms,  the  bluish  color  of  the  surface  in  the 
stage  of  collapse,  and  the  epidemic  character  of  the  more  fatal  dis- 
ease. In  the  presence  of  the  cholera  bacillus  in  the  evacuations,  and 
in  the  speedy  collapse,  lie,  even  in  doubtful  cases,  the  proofs  that  we 
are  dealing  with  malignant  cholera ;  for  sometimes  rice-water  dis- 
charges occur  in  bad  cases  of  cholera  morbus ;  occasionally,  too,  this 
disorder  appears  to  be  epidemic ;  but  it  is  only  so  on  a  very  small 
scale.     To  speak  more  accurately,  it  is  an  endemic  on  a  large  scale. 

The  mortality  of  cholera  is  very  various.  In  many  epidemics  one- 
half,  or  more  than  one-half,  die.  In  some  the  havoc  is  far  less.  The 
first  cases  that  occur  almost  invariably  perish  ;  and,  taken  altogether, 
the  malady  ranks  among  the  most  destructive  to  life.  Its  epidemic 
visitations  are  what  the  plague  was  to  the  Europeans  of  the  seven- 
teenth century,  and  what  yellow  fever  still  is  to  the  inhabitants  of  this 
continent. 

SECTION  III. 

DISEASES    OF    THE    LIVER. 

The  physical  characteristics  of  disease  of  the  liver  have  been 
already  discussed.     Let  us  now  look  at  some  of  the  symptoms. 

Pain  is  one  of  these.  It  is  generally  dull,  and  radiates  from  the 
seat  of  the  liver  to  the  upper  portion  of  the  thorax,  to  the  scapula,  to 
the  shoulder,  and  to  the  umbilicus.  Commonly  it  is  persistent  and 
increased  by  strong  pressure.  As  happens  with  other  symptoms  of 
disease  of  the  liver,  with  vomiting,  with  jaundice,  it  may  be  noticed 
that  the  pain  is  sometimes  strangely  periodical,  suggesting  malaria,  but 
uninfluenced  by  quinine.^  Digestive  troubles  are  usual  accompani- 
ments of  hepatic  affections.  They  are  of  all  grades,  from  mere  indi- 
gestion to  the  signs  announcing  chronic  gastritis.  Disturbance  of  the 
portal  circulation  is  another  frequent  consequence  of  disease  of  the 
liver.  The  flow  of  blood  is  interfered  with,  and  the  result  is  seen  in 
the  occurrence  of  dropsy,  of  piles,  of  partial  peritoneal  inflammation, 
of  hemorrhages  from  the  engorged  stomach  and  intestines,  and  of 
enlargement  of  the  spleen  and  of  the  veins  on  the  surface  of  the 
abdomen. 

Jaundice. — The  most  significant  manifestation  of  hepatic  disorder 
is  jaundice.  This  marked  sign  shows  itself  by  the  yellow  tinge  im- 
parted to  the  skin  and  to  the  conjunctiva.     Besides,  icterus  is  usually 

^  See  on  this  subject  a  paper  by  Cyr,  Arch.  Gen.  de  Med.,  May,  1883. 


568  MEDICAL  DIAGNOSIS. 

attended  with  depression  of  spirits  ;  witli  slow  pulse  ;  with  itching  of 
the  skin ;  with  high-colored  urine,  in  which  the  main  ingredients  of 
bile  can  be  detected,  and  sometimes  small  quantities  of  albumin,  or 
hyaline  and  epithelial  casts  without  albumin ;  with  constipation,  the 
fteces  passed  being  hard  and  knotty,  and  often  of  bad  odor,  and 
almost  devoid  of  color,  or  of  a  leaden  hue. 

Jaundice  is  due  to  the  presence  of  biliary  constituents  in  the 
blood ;  they  get  there  from  the  bile,  in  consequence  of  some  impedi- 
ment to  its  outward  passage,  being  reabsorbed  and  conveyed  into  the 
circulation  ;  or  it  happens  because  the  liver-cells  cannot  perform  their 
functions ;  or  because  some  poison  changes  the  proper  relation  be- 
tween blood-destruction  and  cell-action  in  the  liver ;  or  the  bile  pig- 
ments may  be  formed  directly  from  haemoglobin  without  the  agency 
of  the  liver-cells  ;  for  this,  too,  is  a  view  of  toxaemic  jaundice  with 
blood-destruction  that  seems  best  to  apply  to  certain  cases. 

The  diagnosis  of  jaundice  is  easy.  The  only  morbid  signs  with 
which  it  is  liable  to  be  confounded  are  the  slightly  yellowish  hue  of 
chlorosis,  or  of  some  cachectic  conditions  combined  with  organic 
visceral  disease,  and  the  yellow  appearance  of  the  conjunctiva  which 
is  natural  to  some  persons.  The  changed  color  of  the  countenance 
due  to  chlorosis  is  told  by  its  association  with  a  bluish-white  or  pearly- 
tinted  eye,  and  with  pale  lips  and  tongue  and  transparent  ear.  The 
absence  of  a  yellow  tint  from  the  conjunctiva  is  of  equal  impor- 
tance in  discriminating  from  jaundice  the  yellowish  hue  of  cancer,  of 
malaria,  of  lead  poisoning,  and  of  granular  kidneys.  The  history  of 
the  case  also  aids  us.  The  yellow  look  of  the  eye  sometimes  found 
in  health,  and  at  times  dependent  on  subconjunctival  fat,  is  known  by 
the  unequal  distribution  of  the  color  and  by  the  absence  of  a  yellow 
hue  of  the  complexion.  But  in  negroes — and  it  is  in  them  especially 
that  we  meet  with  the  discolored  conjunctiva — we  have  to  judge  by 
the  character  of  the  coloration  alone.  In  any  doubtful  case,  the 
chemical  tests  for  bile-pigment  in  the  urine  will  solve  the  doubt.  Yet 
there  is  a  form  of  jaundice,  the  so-called  acholuric  jaundice,  in  which 
neither  bile-pigment  nor  urobilin  is  found  in  the  urine,  but  in  which 
a  yellowish  discoloration  of  the  skin  is  very  marked,  and  urobilin 
and  other  biliary  pigments  are  present  in  the  serum  of  the  blood. 
It  is  a  chronic  disorder,  occurring  in  neurasthenic  and  in  dyspeptic 
persons,  especially  in  those  with  hyperacidity.^  The  conjunctiva  has 
only  a  very  slightly  yellowish  tinge. 

When  once  jaundice  has  been  recognized,  the  difficulty  in  diagnosis 

1  Hayem,  Bull,  et  Mem.  de  la  Soc.  Med.  des  Hop.  de  Paris,  May,  1897. 


DISEASES  OF  THE  LIVER.  569 

may  be  said  to  begin.  Of  the  many  distinct  sources  of  icterus,  wliich 
one  is  before  us  ?  Now,  clinically  speaking,  the  causes  may  be  thus 
grouped:  1.  Diseases  of  the  liver.  2.  Diseases  of  the  bile-ducts.  3. 
Diseases  of  parts  remote  from  the  liver,  or  general  diseases  leading  to 
a  disorder  of  the  viscus.  4.  Certain  poisons  acting  upon  the  blood. 
In  the  first  two  of  these  causes  there  is,  as  it  were,  a  mechanical  dif- 
ficulty impeding  or  arresting  the  excretion  of  bile ;  in  the  third  and 
fourth  no  impediment  exists. 

1.  The  jaundice  connected  with  diseases  of  the  liver  is,  as  a  rule, 
recognized  by  its  association  with  changed  dimensions  of  the  organ, 
and  with  pain  or  other  palpable  signs  referred  to  the  hepatic  region. 
It  is  met  with  in  all  disorders  of  the  liver,  but  does  not  exist  in  all  in 
the  same  degree  of  intensity.  It  reaches  a  high  development  and  is 
combined  with  brain  symptoms  in  acute  yellow  atrophy.  In  fatty 
liver,  in  waxy  liver,  in  cancer,  in  cirrhosis,  and  in  acute  hepatitis,  it  is 
not  marked,  and  may  be,  indeed,  absent :  in  truth,  it  can  hardly  be 
looked  upon  as  belonging  to  the  first-mentioned  morbid  states.  The 
jaundice  of  this  class  of  cases  is  due  to  interference  with  the  secreting 
function  of  the  liver-cells. 

2.  Jaundice  arising  from  disease  of  the  larger  biliary  ducts,  such 
■as  their  catarrhal  swehing ;  or  in  consequence  of  their  obstruction  by 
pressure  exercised  by  a  morbid  enlargement  of  the  adjacent  parts,  as 
of  the  pyloric  extremity  of  the  stomach  or  the  pancreas  ;  or  by  tumors, 
.aneurismal,  cancerous,  or  fecal,  closing  the  orifice  of  the  duct ;  or  by 
tumors  of  the  gall-bladder  and  bile-ducts ;  or  by  the  stoppage  of  the 
•ducts  by  inspissated  bile  or  a  biliary  calculus,  or  by  hydatids  or  for- 
eign bodies  from  the  intestines, — is  a  form  of  the  malady  in  which  the 
icterus  is  commonly  intense.  The  obstructive  jaundice  occasions  no 
head  symptoms ;  and  when  these  are  absent  in  a  case  of  very  deep 
jaundice,  when,  further,  the  stools  are  completely  discolored,  we  are 
.generally  correct  in  attributing  the  morbid  phenomena  to  an  impedi- 
ment to  the  flow  of  bile  through  the  common  bile-duct  or  the  hepatic 
duct. 

In  the  jaundice  due  to  reabsorption — precisely  the  form  of  jaun- 
dice, therefore,  that  happens  if  any  serious  obstacle  in  the  biliary  pas- 
sages exist — the  biliary  acids  pass  into  the  blood,  and  thence  into  the 
urine.  But  this  is  not  a  certain  sign  of  obstructive  jaundice ;  for  in 
the  other  forms  of  jaundice,  as  in  the  non-obstructive,  they  may  be 
present,  though  in  lesser  amounts,  and  traces  of  the  bile-acids  may  be 
found  even  in  healthy  urine. 

3.  Illustrations  of  jaundice  following  some  local  lesion  of  other 
parts  of  the  body,  or  appearing  in  the  course  of  an  infective  disease. 


570  MEDICAL  DIAGNOSIS. 

are  furnished  by  the  jaundice  which  happens  in  some  cases  of  pneu- 
monia, or  in  peritonitis,  or  which  is  encountered  in  pyaemia,  in  remit- 
tent, in  typhus,  in  relapsing,  or  in  yellow  fever.  In  these  fevers  the 
yellow  hue  is  generally  found  to  be  connected  with  structural  changes 
in  the  organ.  But,  besides  the  interference  with  the  secreting  action 
of  the  cells,  the  blood  alterations  in  non-obstructive  jaundice  must  be 
considered  ;  there  is  certainly  increased  corpuscular  destruction.  But 
the  blood-change  may,  the  observations  of  Afanassiew  and  others 
prove,  lead  to  mcreased  ^dscidity  of  the  bile,  and  compression  of  the 
bile  capillaries ;  thus  the  jaundice  is  really  in  part  obstructive. 

To  recognize  the  form  of  jaundice  under  discussion,  we  must  ex- 
amine all  the  viscera  of  the  body  with  care,  laying  stress  upon  the 
history  of  the  case  and  the  phenomena  attending  the  jaundice. 

4.  Poisons  acting  upon  the  blood  sometimes  give  rise  to  jaundice 
very  rapidly ;  for  instance,  the  jaundice  from  snake-bites  or  from 
pysemic  affection  is  apt  to  be  suddenly  developed.  As  a  rule,  the  tint 
is  light.  In  the  history  of  the  accident  and  the  signs  of  alteration  of 
the  blood  we  possess  the  means  of  distinguishing  this  form  of  jaun- 
dice. Certain  mineral  poisons,  such  as  phosphorus,  copper,  anti- 
mony, come  into  the  same  category.  Chloroform  and  ether,  too,  lead 
to  abnormal  blood-changes  producing  jaundice.  The  deep  jaundice 
of  arsenuretted  hydrogen  and  of  toluyindianin  is  largely  obstructive, 
caused  by  the  irritant  action  of  products  in  the  bile.  As  a  general 
fact  it  may  be  stated  that  in  all  these  kinds  of  toxeemic  jaundice,  the 
icterus  is  apt  to  be  light,  but  the  constitutional  symptoms  are  severe  ; 
bile  is  not  wholly  absent  from  the  stools. 

The  urine  enables  us  to  a  certain  extent  to  tell  blood  jaundice 
from  jaundice  caused  by  liver  disord^.  We  find,  besides  an  excess 
of  urobilin,  liEemoglobin  in  the  urine,  or  get  from  its  hgematin  the 
haemin  crystals  of  Teichmann.  These  are  obtained  by  drying  urme 
on  a  slide,  adding  a  little  salt,  and  then  glacial  acetic  acid  under  the 
cover-glass.  The  slide  is  heated  until  bubbles  rise,  and  on  cooling 
the  characteristic  blood-crystals  form. 

Thus,  then,  we  can  bring,  clinically  speaking,  most  of  the  varieties 
of  jaundice  under  one  or  the  other  of  the  four  heads  mentioned ;  and, 
roughly  speaking,  they  come  really  under  two, — obstructive  jaundice, 
where  the  disorder  results  from  obstruction  of  the  common  duct,  and 
jaundice  without  such  obstruction.  But  there  are  a  few  kinds  of  jaun- 
dice which  it  is  not  easy  to  classify  with  precision  :  one  of  these  is  the 
jaundice  from  mental  emotion. 

As  regards  this,  no  satisfactory  explanation  has  been  given.  All 
we  know  is,  that  violent  anger  or  fright  may  lead  within  a  very  brief 


DISEASES  OF  THE  LIVER. 


571 


space  of  time  to  the  development  of  jaundice,  and  that  the  quickly 
occurring  discoloration  is  not  dangerous  or  of  long  duration.  The 
perverted  innervation  caused  by  concussion  of  the  brain  leads  to  a 
similar  kind  of  jaundice  as  that  from  emotion.  It  is  thought  by  some 
that  a  spasm  of  the  bile-ducts  obstructs  the  flow  of  bile ;  by  others- 
that  the  haemoglobin  of  the  blood,  instead  of  breaking  up  into  normal 
bile  pigment,  may  break  up  into  abnormal  pigment,  and  that  the  icterus, 
is  really  a  urobilin  jaundice,  which  gives  rise  to  the  icteric  skin  and 
conjunctiva. 

If  icterus  last  upward  of  two  months  it  is  always  a  matter  of  some 
danger,  as  showing,  in  all  likelihood,  an  organic  lesion  of  the  liver  or 
of  the  biliary  passages,  or  unyielding  pressure  on  them.  Unfavor- 
able, too,  is  it  if  the  discoloration  of  the  skin  be  attended  with  cere- 
bral symptoms,  or  accompany  affections  of  the  blood,  or  be  associated 
with  wide-spread  ecchymoses,  or  a  very  dark  color  of  the  skin.  In- 
deed, cases  of  "  green"  or  "  black"  jaundice  generally  prove  fatal. 

Before  examining  the  hepatic  maladies  according  to  their  clinical 
features,  let  us  look  at  their  pathological  classification : 


Diseases  of  the  Liver. 


Diseases  of  he- 
patic paren- 
chyma. 


Hyperfemia. 


Inflammation  and  its  conse- 
quences   

Atrophy 

Hypertrophy 


Degeneration 
mations  .  . 


and    new   for- 


Acute  congestion. 

Chronic  congestion; 

Acute  hepatitis. 

Chronic  hepatitis. 

Interstitial  inflammation ;  cir- 
rhosis, atrophic  and  hyper- 
trophic. 

Abscess. 

Softening. 

Syphihtic  hepatitis. 

Acute  yellow  atrophy. 

Simple  chronic  atrophy. 

Red  atrophy. 

Partial. 

General. 
'  Fatty  liver. 

Waxy  liver. 

Pigment  liver. 

Cancer. 

Sarcoma. 

Lymphatic  growths, 

Gummata. 

Tubercle. 

Hydatids. 

Simple  cysts. 


572  MEDIC  AlilDIAGNOSIS. 

Diseases  of  the  Liver. — Continued. 

Inflammation  of  gall-bladder   (  Catarrhal. 

(cholecystitis)     and      gall-  \  Exudative. 

ducts  (cholangitis) '-  Suppurative. 

Diseases  of       Occlusion  of  biliary  passages. 

biliary  pas-  <   Dilatation  of  gall-bladder. 

sages.  Morbid  growths. 

Foreign  bodies  ;   concretions, 

such  as  gall-stones. 

Biliary  fistulce. 

r  Inflammation. 

I   Of  hepatic  artery J   Sclerosis. 

, ,      ,  (  Aneurism. 

blood  -  ves-  ^   Qf  hepatic  vein. 


Diseases  of 
bloc 
sets 


I   Of  portal  vein  J  Suppurative  inflammation. 

i  Thrombosis. 


Acute  Diseases  of  the  Liver  attended  generally  with  Shght 
Enlargement  of  the  Organ,  and  with  more  or  less,  though 
rarely  much,  Jaundice. 

Acute  Congestion. — This  arises  from  organic  disease  of  the 
heart,  from  obstructed  portal  circulation,  from  irritating  food  and 
clrink  and  disturbed  digestion,  from  gastric  or  intestinal  catarrh,  or 
from  malarial  poison  ;  sometimes  it  is  caused  by  a  liigh  temperature, 
by  a  blow  on  the  hepatic  region,  by  arrest  of  the  menstrual  flow,  by 
a  protracted  cliill,  by  violent  exercise,  or,  as  Frerichs  points  out,  by 
injury  to  the  semilunar  ganglia.  The  acute  congestion  is  character- 
ized by  pain  m  the  right  shoulder  and  loin,  by  an  unpleasant  sensation 
of  weight  and  of  tension  in  the  right  hypochondrium,  mcreased  after 
meals,  and  by  nausea  and  vomiting.  At  the  same  time  the  action  of 
the  bowels  is  deranged,  being  generally  too  frequent ;  the  tongue  is 
coated  ;  there  is  flatulency,  as  well  as  depression  of  spirits,  with  loss 
of  appetite  and  of  strength  ;  and  the  liver  is  somewhat  enlarged.  But 
we  find  ordinarily  only  slight  jaunchce,  and  no  fever.  Gradually 
these  signs  disappear  ;  the  increased  hepatic  dulness,  however,  remain- 
ing for  some  time  after  the  gastric  and  intestinal  disturbances  have 
abated.  These  always  bear  a  marked  relation  to  congestion  of  the 
liver,  both  as  cause  and  as  efi'ect.  The  acute  disorder  may  gradually 
pass  into  a  chronic  hypereemia. 

Acute  Hepatitis. — The  symptoms  of  this  affection  are  much  the 
same  as  those  of  acute  congestion,  except  that  we  observe  rise  of 
temperature,  and  in  some  cases  enlargement  of  the  spleen,  and  albu- 
min in  the  urine.     The  pain  is  dull,  and  is  increased  on  pressure,  yet 


DISEASES  OF  THE  LIVER.  573 

not  much  so,  unless  the  peritoneal  covering  of  the  liver  be  involved. 
But  acute  hepatitis  is  not  a  well-defined  affection,  and  we  know  little 
of  it  except  in  connection  with  dj^sentery,  particularly  with  amoebic 
dysentery.  In  hot  climates  it  often  terminates  in  suppuration,  and 
pus  collects  in  the  substance  of  the  liver.  The  occurrence  of  this,  the 
tropical  abscess,  as  Murchison  ^  calls  it,  is  indicated  by  recurring  rigors, 
by  fever  of  remittent  type,  by  clammy  perspirations,  by  prostration 
and  loss  of  flesh.  Not  infrequently,  too,  a  decided  fulness  of  the  side 
may  be  noticed,  and  occasionally  careful  palpation  detects  deep-seated 
fluctuation.  After  an  abscess  has  formed,  the  danger  is  great ;  sec- 
ondary abscess  may  follow,  and  the  patient  is  apt  to  perish  from  peri- 
tonitis, or  from  blood  poisoning.  Yet  recovery  may  take  place.  The 
matter  may  be  discharged  through  the  abdominal  walls,  or  burst  into 
the  intestine,  or  find  its  way  through  the  diaphragm  into  the  pleural 
cavity,  to  be  discharged  through  the  lung.  But,  as  the  phenomena  of 
abscess  of  the  liver  following  acute  inflammation  are  in  the  main  the 
same  as  when  the  suppurative  hepatitis  is  consecjuent  upon  other  mor- 
bid states,  we  shall  not  here  consider  what  we  shall  presently  fully 
examine.  The  pysemic  liver  abscess  is  the  one  of  greatest  similarity. 
The  maladies  resembling  acute  congestion  or  acute  hepatitis  are : 

PEmHEPATITIS  ; 

Inflammation  of  the  Portal  Veins  ; 

Pigment  Liver  ; 

Chronic  Hepatic  Diseases  with  Acute  Symptoms  ; 

Acute  Non-Hepatic  Diseases  with  Jaundice  ; 

Diaphragmatic  Pleurisy  ; 

Acute  Infectious  Jaundice  ; 

Inflammation  of  the  Biliary  Passages  ; 

Acute  Yellow  Atrophy. 

Perihepatitis. — Inflammation  limited  to  the  serous  covering  of  the 
liver  is  not  a  frecfuent  disease.  Unless  it  be  of  syphilitic  origin,  it  is 
scarcely  ever  observed  as  a  primary  affection  ;  it  is  generally  caused 
by  the  extension  of  inflammation  from  parts  adjacent  to  the  liver, — 
as  from  the  stomach,  intestines,  diaphragm,  or  pleura, — or  of  a  chronic 
peritonitis  ;  or  it  is  an  attendant  upon  disease  of  the  liver  itself.  In 
the  latter  case  it  presents  no  peculiar  symptoms,  except  that  it  adds 
tenderness  to  the  signs  of  the  hepatic  malady  it  complicates.  Its  most 
marked  signs  are,  besides  the  decided  tenderness,  severe  pain  upon 
motion  or  deep  inspiration,  and  marked  increase  of  the  pain  when  the 
patient  lies  on  either  side  ;  an  occasional  grating  friction  sound ;  and  a 

^  Diseases  of  the  Liver,  2d  edit.,  1877. 
36 


574  MEDICAL  DIAGNOSIS. 

normal  or  increased  size  of  the  gland.  The  history  of  the  case,  especially 
its  association  with  interstitial  nephritis,  chronic  peritonitis  or  ascites, 
tenderness  over  the  spleen  from  coexisting  inflammation  of  its  capsule 
absence  of  jaundice,  and  slight  fever  are  also  signs  of  value.  The 
smaller  size  of  the  liver,  the  absence  of  tenderness  localized  over  it, 
and  the  rapidly  forming  and,  after  tapping,  quickly  recurring  dropsy, 
distinguish  cirrhosis  of  the  liver  with  peritoneal  involvement  from 
perihepatitis.  The  latter  affection,  certainly  the  chronic  hyperplastic 
form,  has  generally  an  acute  beginning  and  runs  a  slow  course ;  the 
ascites  often  becomes  stationary.^ 

Inflammation  of  the  Portal  Veins  ;  Pylephlebitis. — An  inflammation 
of  the  portal  veins,  terminating  in  suppuration  or  their  infection  by  a 
general  pysemia,  or  through  local  processes  in  the  portal  circle,  is  very 
liable  to  be  mistaken  for  suppurative  hepatitis.  Nor  are  there,  in  truth, 
any  positive  symptoms  by  which  we  can  discrimmate  between  the  two 
maladies.  Still,  we  may  suspect  that  the  veins,  rather  than  the 
structure  of  the  liver,  are  the  seat  of  inflammation,  if,  with  the  signs 
of  acute  and  painful  enlargement  of  the  organ,  we  find  jaundice,  thin 
and  copious  stools,  irregular  fever  and  profuse  sweats,  occasional 
chifls,  emaciation,  increase  in  the  size  of  the  spleen,  typhoid  symp- 
toms, without  apparent  fluctuation  or  other  signs  of  an  hepatic  ab- 
scess ;  if  there  exist  pains  in  the  epigastrium  or  right  hypochondrium, 
or  shooting  to  the  lumbar  and  sacral  regions  ;  if  following  these  symp- 
toms appear  swelling  of  the  veins  of  the  abdominal  walls  and  striking 
evidences  of  hectic  fever  or  of  peritonitis  ;  and  if  these  phenomena  be 
encountered  in  a  person  who,  on  account  of  a  previous  affection  of 
the  intestines  or  the  appendix  or  the  spleen,  or  of  any  other  organ 
having  a  connection  with  the  portal  circulation,  is  liable  to  disease  of 
the  portal  system.  Marked  enlargement  of  the  spleen  is  a  constant 
feature  of  impediment  in  the  portal  vein,  whether  from  inflammation 
or  from  thrombosis. 

Pigment  Liver. — In  accumulation  of  pigment  in  the  liver,  which  is 
most  common  as  the  result  of  a  deep  malarial  poisoning,  the  liver  is 
not  the  only  organ  implicated  in  the  morbid  process :  the  spleen  is 
commonly  affected ;  the  blood  becomes  anaemic,  contains  the  malarial 
corpuscles  and  large  quantities  of  pigment,  and  pigment  accumulates 
in  the  kidneys  or  in  the  brain.  Now,  the  effect  of  all  this  is  to  occa- 
sion marked  symptoms,  JDesides  those  referable  to  the  derangement 
of  the  liver ;  for  it  is  not  unusual  to  find  grave  cerebral  disturbance, 
albuminuria,  hemorrhage  from  the  intestines,  profuse  diarrhoea,  and 

1  Schmaly  and  Webber,  Deutsche  Med.  Wochenschrift,  1899,  No.  12. 


DISEASES  OF  THE  LIVER.  575 

enlargement  of  the  spleen.  The  fever  that  accompanies  the  morbid 
condition  is  apt  to  be  of  an  intermittent  type  ;  the  jaundice  is  gener- 
ally slight.  In  India,  pigmentary  degeneration  of  the  liver  tends  to 
suppurative  hepatitis.^ 

Chronic  Hepatic  Diseases  ivith  Acute  Symptoms. — We  occasionally 
meet  with  patients  who  seem  to  be  laboring  under  an  acute  affection 
of  the  liver,  either  some  form  of  inflammation  of  the  liver-structure 
or  of  the  biliary  passages,  or  congestion  of  the  liver,  but  in  whom  the 
acute  symptoms  have  merely  supervened  upon  a  chronic  complaint. 
Such  cases  are  puzzling ;  we  may  have  to  wait  for  their  solution  until 
the  acute  symptoms  subside.  In  hepatic  cancer  the  sudden  and  rapid 
development  of  the  malady  amid  the  signs  of  acute  congestion  is  not 
very  uncommon.  Occasionally  the  peculiar  physical  phenomena  of 
individual  hepatic  diseases,  such  as  the  nodular  tumors  of  a  malig- 
nant growth,  or  the  fluctuation  of  a  hydatid  cyst,  will  assist  materially 
in  the  diagnosis. 

Acute  Non-Hepatic  Diseases  with  Jaundice. — There  are  many  acute 
affections,  such  as  pneumonia,  pyaemia,  puerperal  fever,  and  some 
forms  of  sepsis,  in  which  jaundice  may  coincide  with  febrile  symp- 
toms and  excite  suspicions  of  liepatitis.  But  the  yellowness  of  the 
skin  which  may  attend  the  non-hepatic  disorders  mentioned  is  accom- 
panied by  symptoms  so  different  that  a  mistake  is  not  likely  to  arise 
if  the  history  of  the  case  be  taken  into  account  and  other  viscera 
besides  the  liver  be  explored. 

Diaphragmatic  Pleurisy. — Inflammation  of  the  pleural  covering  of 
the  diaphragm  may  give  rise  to  symptoms  that  point  to  an  acute  affec- 
tion of  the  liver.  We  fnid  pain  in  the  right  hypochondrium,  nausea 
and  vomiting,  dry  cough,  and  embarrassed  respiration.  But  the  pain 
in  diaphragmatic  pleurisy  is  far  greater  than  even  in  perihepatitis,  is 
more  suddenly  developed,  and  is  much  more  aggravated  by  move- 
ments and  by  full  inspiration.  The  diaphragm  on  one  side  is  im- 
movable ;  the  hypochondriac  region  is  retracted ;  the  breathing  is 
purely  costal  and  short ;  the  difficulty  in  breathing  amounts  to  orthop- 
noea ;  the  body  is  bent  forward.  We  often  encounter  hiccough,  great 
anxiety,  sometunes  delirium,  attacks  like  angina,  a  sardonic  grin  on 
the  features,  a  cough  that  comes  on  in  frequent  paroxysms  ;  and  al- 
though, as  a  case  recorded  by  Andral  ^  proves,  there  may  be  jaundice, 
yet  this  is  in  reality  so  generally  wanting  as  scarcely  to  belong  to  the 
symptoms  of  diaphragmatic  pleurisy.  Then  in  this  complaint  we  per- 
ceive friction  sounds, — though  the  physical  signs  will  not  always  aid 

^  Aitken's  Practice  of  Medicine,  vol.  ii. 
^  Clinique  Medicale,  tome  ii. 


576  MEDICAL  DIAGNOSIS. 

US,  being  often  uncertain,  mostly  out  of  all  proportion  to  the  gravity 
of  the  general  symptoms,  and  consisting  simply  in  enfeebled  breath- 
ing, with  perhaps  a  few  fine  moist  rales  at  the  lower  portion  of  one 
side  of  the  chest.  Fever  may  be  slight  or  marked ;  it  is  generally 
ushered  in  by  a  chill.  There  is  usually,  in  addition  to  the  pain  along 
the  cartilages  of  the  false  ribs,  which  is  readily  evoked  by  pressure,  a 
tender  spot  in  the  epigastrium,  on  a  level  with  the  tenth  rib,  one  or 
two  fmger-breadths  from  the  linea  alba.  There  are  shooting  pains 
along  the  clavicle  and  in  the  tract  of  the  superficial  cervical  plexus, 
and  the  phrenic  nerve  of  the  affected  side,  pressed  on  in  the  neck,  is 
very  sensitive.  The  pain  on  pressure  is  most  intense  along  the  costal 
insertions  of  the  diaphragm,  especially  of  the  tenth  rib ;  it  is  stated 
that  upward  pressure  affords  a  means  of  diagnosis,  as  it  relieves  the 
pleuritic  pain.^  The  difficulty  in  expectorating,  owing  to  the  pain, 
may  be  so  great  as  to  hasten  death.^ 

Acute  Infectious  Jaundice. — This  malady,^  also  known  as  WeiVs 
disease,  presents  symptoms  of  an  acute  hepatitis.  But  it  is  probably 
not  a  disease  of  the  liver  at  all,  but  rather  an  infectious  fever  due  to 
the  invasion  of  a  specific  micro-organism  through  the  gastro-intestinal 
tract.  Jaeger^  has,  in  cases  of  Weil's  disease,  isolated  from  the  urine 
during  life  and  from  the  tissues  after  death  a  short  curved  rod,  pro- 
vided with  cilia,  which  he  designates  "  bacillus  proteus  flavescens." 
Weil's  disease  is  marked  by  jaundice,  swelling  of  the  spleen,  nephritis, 
and  blood-alteration.  It  mostly  affects  vigorous  young  men  in  hot 
weather ;  butchers  and  soldiers  are  especially  liable  to  it.  It  has  been 
also  observed  in  persons  who  have  bathed  in  water  contaminated  by 
fowls  suffering  from  an  analogous  disorder,^  and  in  epidemics.  It 
begins  abruptly  with  headache,  dizziness,  and  decided  elevation  of 
temperature.  The  jaundice  is,  as  a  rule,  moderate,  the  liver  slightly 
swollen  and  painful ;  there  is  great  weakness,  with  delirium  and  som- 
nolency, increased  thirst,  and  general  malaise,  with  loss  of  appetite. 
Besides  albumin  and  tube-casts,  the  urine  may  contain  blood ;  both 
bile-pigment  and  bile-acids  are  found  in  it.  There  are  pains  in  the 
limbs,  especially  in  the  calves ;  the  bowels  are  usually  loose.  The 
symptoms  abate  quickly ;  from  the  seventh  to  the  eighth  day  the  tem- 
perature falls  gradually  to  normal,  but  the  fever  may  last  from  ten  to 

^  British  Medical  Journal,  Aug.  1871. 

^  Frank  Donaldson,  Jr.,  Amer.  Journ.  Med.  Sci.,  April,  1885. 
'^  Described  by  Weil,  Deutsches  Archiv  fiir  klin.  Med.,  Bd.  xxxix. 
*  Zeitschrift  fiir  Hygiene  und  Infektionskrankheiten,  Dec.  9,  1892. 
^  Jaeger,  loc.  cit. 


DISEASES  OF  THE  LIVER.  577 

fourteen  days.  A  return  of  fever  after  a  period  of  its  absence  from 
one  to  seven  days  may  happen,  but  this  return  does  not  last  more 
than  three  to  six  days.  The  convalescence  is  extremely  slow.  Fatal 
cases  have  presented  fatty  degeneration  of  the  liver,  acute  paren- 
chymatous nephritis,  and  enlargement  of  the  spleen.^  The  disease 
resembles  relapsing  fever ^  but  the  spirilla  have  not  been  found  in  the 
blood.  Nor  is  defervescence  attended  with  a  critical  discharge  fol- 
lowed by  subnormal  temperature.  Further,  the  ascent  of  the  tem- 
perature of  the  secondary  fever  is  gradual,  while  that  of  the  parox- 
ysm of  relapsing  fever  is  sudden.  The  return  of  the  fever  makes  it 
unlike  abortive  typhoid  with  bilious  symptoms.  Then  it  shows  no 
eruption,  except  herpes  and  an  erythema.^  Besides,  jaundice  and 
urine  containing  blood  are  rare  in  typhoid  fever. 

Between  acute  yelloiv  atrophy  of  the  liver  and  Weil's  disease  there 
is  a  close  resemblance.  But  the  former  has  a  prodromal  period, 
while  the  onset  of  the  latter  is  abrupt.  The  second  is  attended  with 
elevation  of  temperature  of  peculiar  range ;  in  the  first  the  tempera- 
ture is,  as  a  rule,  not  elevated,  and  may  be  subnormal,  and  the 
bowels  are  constipated.  In  acute  yellow  atrophy  the  jaundice  is 
gradually  progressive  and  the  liver  is  at  first  enlarged  and  subse- 
quently reduced  in  size  ;  the  jaundice  of  Weil's  disease  is  slight  and 
soon  subsides,  and  the  liver  remains  enlarged  throughout  the  attack. 
In  acute  yellow  atrophy  the  urine  may  contain  albumin  and  tube- 
casts,  but  there  are  not  the  pronounced  symptoms  of  nephritis  that 
Weil's  disease  presents.  The  tendency  to  hemorrhages  is  far  greater 
in  acute  atrophy  of  the  liver  than  in  infectious  jaundice.  The  one 
condition  is  almost  invariably  fatal ;  the  other  is,  as  a  rule,  followed 
by  rapid  improvement  and  recovery.  Weil's  disease  in  some  respects 
resembles  yellow  fever,  but  it  is  an  affection  of  several  paroxysms. 

Inflammation  of  the  Gail-Bladder  and  Gall-Ducts. — The 
symptoms  of  this  vary  materially  according  to  the  parts  specially 
affected,  as  well  as  to  the  kind  of  inflammation,  whether  suppurative 
or  not.  When  the  gall-bladder  alone  is  inflamed,  we  have  cholecys- 
titis;  when  the  bile-ducts  alone,  especially  the  flner  ducts,  cholangitis, 
which  is  generally  infective  or  suppurative.  The  most  common  form 
of  inflammation  by  far  is  inflammation  of  the  ductus  choledochus, 
chiefly  at  its  terminal  portion,  and  catarrhal. 

Catarrhal  Jaundice. — The  morbid  process  is  nearly  always  prop- 
agated from  the  stomach  or  intestines,  and  nausea,  furred  tongue,  a 

^  Jaeger,  loc.  cit. 

^  Fiedler,  Deutsches  Archiv  f.  klin.  Med.,  Feb.  1888. 


578  MEDICAL  DIAGNOSIS. 

feeling  of  Aveight  in  the  epigastrium,  feverishness,  and  diarrhoea  occur 
previously  to  the  discoloration  of  the  faeces,  to  the  jaundice,  to  the  in- 
creased hepatic  dulness,  and  to  the  slight  tenderness  on  pressure  in 
the  right  hypochondrium  ;  in  other  words,  the  symptoms  of  gastric  or 
gastro-intestinal  catarrh  precede  those  of  "icterus  catarrhalis." 

Catarrhal  icterus  does  not  cause  any  great  enlargement  of  the 
liver,  and  the  slightly  swollen  organ  remains  smooth  on  palpation. 
Nor  is  the  tenderness  decided,  except  over  the  tumid  and  projecting 
gall-bladder.  The  jaundice,  at  first  slight,  becomes  after  a  few  days, 
as  the  duct  is  obstructed,  intense,  and  the  stools  are  white  and  devoid 
of  bile.  There  is  now  no  fever,  or  this  is  but  very  slight ;  the  pulse 
is  usually  slow.  The  affection  is  the  most  common  cause  of  marked 
jaundice  in  young  persons  ;  when  found  in  the  middle-aged  or  in  the 
old  it  is  apt  to  be  associated  with  a  gouty  diathesis  or  to  have  followed 
syphilis  ;  and  at  any  age  it  may  be  secondary  to  other  diseases  of  the 
liver,  or  to  gall-stones,  and  is  then  apt  to  be  more  lasting. 

Generally  catarrhal  icterus  is  a  tractable  disorder,  and  after  con- 
tinuing for  two  or  three  weeks,  it  usually  subsides.  But  it  may  per- 
sist for  as  many  months  ;  and  in  rare  instances  the  inflammation  leads 
to  an  occlusion  of  the  common  duct,  and  to  a  fatal  issue.  I  had  such 
a  case  in  1863  under  my  charge  at  the  Philadelphia  Hospital.  The 
patient,  a  man  upward  of  sixty  years  of  age,  died  deeply  jaundiced 
and  comatose.  He  had  presented,  during  life,  the  signs  of  enlarge- 
ment of  the  liver ;  little  or  no  tenderness  in  the  hepatic  region  ;  no 
fever;  but  much  gastric  irritability  and  obstinate  constipation,  both 
of  which  had  existed  for  three  weeks  prior  to  a  noticeable  discolora- 
tion of  the  skin.  The  disease  was,  as  far  as  could  be  ascertained, 
of  only  two  months'  duration ;  and  the  jaundice  steadily  deepened 
from  the  time  of  its  first  appearance.  At  the  autopsy,  the  gall- 
bladder was  found  enormously  distended,  its  coats  thin,  yet  otherwise 
scarcely  abnormal ;  but  the  common  duct  was  obliterated  by  inflam- 
mation. The  stomach  and  the  upper  bowel  were  congested,  while 
the  coats  of  the  stomach  towards  the  pylorus  were  thickened.  A 
similar  case  has  been  described  by  Tyson.^ 

Now,  it  is  not  generally  difficult  to  distinguish  catarrhal  jaundice, 
except  in  those  very  exceptional  cases  in  which  the  common  duct  or  the 
hepatic  duct  is  obliterated.  It  differs  from  congestion  of  the  liver  by  the 
different  etiological  elements, — the  one  disorder  happening  commonly 
in  connection  with  disease  of  the  heart,  or  an  obstruction  of  the  portal 
circulation,  or  a  miasmatic  poison  ;  the  other  following  usuafly  exposure 

^  Transactions  of  the  Pathological  Society  of  Philadelphia,  vol.  iv. 


DISEASES  OF  THE  LIVER.  579 

to  cold  and  damp,  or  the  eating  of  quantities  of  indigestible  food. 
Then,  inflammation  of  the  gall-ducts  gives  rise  to  decided  jaundice. 

Catarrhal  jaundice  may  occur  as  an  accompaniment  of  some  gen- 
eral morbid  condition,  or  in  an  epidemic  form.  The  epidemic  cases 
are  distinguished  by  the  history,  by  the  tendency  to  acute  disease  of 
other  organs,  such  as  the  lungs  and  kidneys,  by  pain  in  the  region 
of  the  liver,  and  by  enlargement  of  the  spleen.^ 

From  the  jaundice  of  chronic  hepatic  maladies — such  as  oanoer 
or  cirrhosis — we  separate  catarrhal  icterus  by  the  non-existence  of 
the  physical  signs  of  these  maladies,  by  its  acute  course,  and  by  the 
dissimilar  progress  of  the  symptoms.  Still,  as  regards  cancer  v^^e 
must  bear  in  mind  that  we  encounter  in  elderly  gouty  persons  cases 
of  long-persisting  catarrhal  icterus  attended  with  frequent  vomiting 
and  marked  emaciation  which  strongly  resemble  cancer,  yet  slowly 
yield  to  treatment.  Inflammation  of  the  biliary  passages  with  the 
jaundice  arising  in  consequence  of  biliary  calculi  is  distinguished  by  the 
severe  pain,  the  sudden  appearance  of  the  icterus  subsequent  to  the 
paroxysms  of  pain,  its  increase  after  them,  and  its  often  rapid  fading 
after  the  gall-stone  is  voided. 

In  some  cases  of  inflammation  of  the  biliary  ducts,  especially 
where  an  occlusion  of  the  ducts  takes  place,  a  peculiar  paroxysmal 
fever  is  developed,  with  temperature  ranging  from  103°  to  105°, 
which  is  readily  mistaken  for  a  malarial  outbreak.  This  hejjatic  fever 
is  generally  ushered  in  by  a  violent  chill,  and  the  paroxysms,  which 
are  repeated  at  regular  times,  are  apt  to  be  followed  by  increased 
jaundice.  Their  irregularity, — to  which,  however,  there  are  excep- 
tions in  the  earlier  part  of  the  case, — their  resistance  to  quinine,  the 
frequent  occurrence  of  vomiting  and  of  pain  in  the  region  of  the 
liver,  the  history  of  the  case,  and  the  absence  of  malarial  corpuscles 
in  the  blood,  distinguish  them  from  malarial  fever.  From  abscess  of 
the  liver  the  affection  is  more  difficult  to  discriminate,  and  we  must 
lay  stress  on  the  deep  jaundice,  which  mostly  happens  after  the  fever 
outbreaks,  and  on  the  different  physical  phenomena.  Sweats  occur 
in  both,  but  they  occur  only  at  the  end  of  the  marked  paroxysms  in 
the  so-called  hepatic  fever.  We  also  find  similar  attacks  of  rigor 
and  intermittent  pyrexia  associated  with  hepatic  pain  in  obstruction 
of  the  common  bile-duct  from  gall-stones.  They  may  go  on  for  years, 
and  lead  to  death  by  ansemia  and  exhaustion,  or  recovery  may  take 
place.     The  temperature  between  the  attacks   is   normal.      Charcot 

^  Heitter,   Wien.    Med.   Wochenschr. ,   1887;    Margotta,    Rivista  Veneta,   Feb. 
1897  ;  Favero,  Gazz.  degli  Osp.,  Jan.  1899. 


580  MEDICAL  DIAGNOSIS. 

looks  upon  them  as  septic,  as  do  Pepper  ^  and  Osier ;  ^  Ord  ^  holds 
the  fever-outbreak  to  be  due  to  irritation  of  the  mucous  membrane,  and 
this  is  the  view  I  hold.  Hepatic  fever  bears  a  close  relation  to  malaria. 
Those  who  have  malarial  poison  in  their  systems  are  more  liable  to  it, 
and  it  is  likely  to  be  in  them  connected  with  a  biliary  catarrh,  and 
with  inspissated  bile  rather  than  with  an  impacted  gall-stone. 

Now,  considering  the  question  of  operative  interference  that  may 
arise,  it  is  of  the  utmost  importance  to  distinguish  the  cases  in  which 
the  obstruction  is  purely  catarrhal  and  not  connected  with  gall-stones 
from  those  in  which  it  is.  Distention  of  the  gall-bladder  will  not 
assist  us,  certainly  not  in  recognizing  the  obstruction  of  the  common 
duct  from  stone,  for  Ecklin  has  found  that  in  nearly  all  cases  the  gall- 
bladder is  contracted.  The  most  certain  test  undoubtedly  would  be 
having  found  gall-stones  on  previous  occasions,  or  finding  them  after 
the  fever  paroxysms.  The  cases  with  gall-stones  are  very  much 
more  frequent  than  the  cases  of  hepatic  fever  without  them ;  the 
jaundice  is  more  distinctly  connected  with  the  attacks,  and  generally 
passes  off  more  completely  between  them ;  the  pain  is  greater  and 
ceases  more  abruptly ;  and  the  febrile  paroxysms  are  not  brought  on 
by  cold,  exposure,  and  fatigue,  as  they  are  often  in  hepatic  fever 
without  gall-stones. 

Acute  Cholecystitis. — This  may  be  the  result  of  the  irritation 
of  gall-stones,  but  often  it  is  not,  and  is  due  to  bacillary  infection  of 
the  gall-bladder,  particularly  in  typhoid  fever ;  it  is  also  observed  as 
a  sequel  to  pneumonia.  At  times  we  meet  with  an  acute  attack 
where  chronic  inflammation  of  the  gall-bladder  is  present,  but  where 
every  now  and  then  there  are  acute  outbreaks.  Such  cases  may  exist 
with  gall-stones,  but  I  have  known  them  without  these,  especially  in 
persons  with  chronic  constipation.  In  some  instances  of  acute  chole- 
cystitis the  cause  remains  obscure. 

The  disease  occurs  in  three  forms,  that  are  not,  however,  very 
sharply  defined  in  their  differences  :  the  catarrhal,  the  suppurative, 
and  the  phlegmonous.  The  most  significant  symptom  in  all  is  the 
severe  pain.  This  often  occurs  in  violent  paroxysms,  and  is  referred 
to  the  seat  of  the  gall-bladder,  or  is  higher  up,  or  epigastric,  or  near 
the  appendix.  It  is  nearly  always  associated  with  marked  tender- 
ness, which  is  not  confined  to  the  region  of  the  gall-bladder,  for  the 
whole  abdomen  may  become  very  sensitive.  Yet  the  tenderness  is 
apt  to  localize   itself  finally  over  the   gall-bladder.     There  is  often 

1  Medical  News,  March  29,  1890. 

^  Johns  Hopkins  Hospital  Reports,  vol.  ii.,  No.  1,  1890. 

*  Boston  Medical  Journal,  1887. 


DISEASES  OF  THE  LIVER.  581 

coexisting  rigidity  of  the  abdominal  walls,  especially  on  the  right  side. 
The  temperature  is  but  slightly  elevated.  Jaundice  is  oftener  absent 
than  present.  I  found  it  in  twenty  of  sixty-one  cases  I  analyzed,  and. 
when  present,  it  is  mostly  slight,  though  before  pronouncing  it  absent 
the  urine  must  be  carefully  examined  for  bile  pigments.  Nausea 
and  vomiting  are  more  constant.  Constipation  is  the  rule,  and  the 
stoppage  of  the  bowel  may  be  so  complete  as  to  be  looked  upon  as 
due  to  acute  obstruction,  and  lead  to  an  operation. 

Tumor  is  as  valuable  a  sign  of  acute  cholecystitis  as  pain,  though 
not  so  usual  a  one.  It  is  at  the  seat  of  the  gall-bladder,  and  is 
found  at  the  junction  of  the  upper  two-thirds  with  the  lower  third  of 
a  line  drawn  from  the  ninth  rib  to  the  umbilicus, — at  Mayo  Robson's 
point.^  The  seat  of  the  sensitive  swelling  is  very  significant  in  dis- 
tinguishing acute  cholecystitis  from  appendicitis.  But  where  this 
affects  the  upper  part  of  the  appendix,  there  are  tenderness  and 
swelling  high  up,  and  not,  as  usual,  in  the  right  iliac  fossa,  over  or 
near  McBurney's  point,  and  an  absolute  differential  diagnosis  may 
become  impossible.  In  three  cases  reported  in  the  admirable  paper 
of  Maurice  Richardson  ^  an  operation  was  performed  for  appendicitis, 
which  from  the  symptoms  appeared  positive,  and  a  distended,  inflamed 
gall-bladder  was  found.  The  swelling  and  the  acute  symptoms  may 
suggest  the  possibility  of  abscess  of  the  liver  near  the  site  of  the  gall- 
bladder, but  there  is  much  more  pain  in  cholecystitis,  and  the  chills, 
the  irregular  fever,  the  sweating  of  abscess  are  wanting. 

There  is  no  certainty  in  the  diagnosis  between  the  different  forms 
of  acute  cholecystitis.  The  suppurative  form  is  most  commonly 
found  in  association  with  gall-stones,  though  we  also  meet  with  it  in 
infective  fevers,  especially  typhoid  fever.  The  empyema  of  the  blad- 
der often  attains  considerable  size,  and  a  marked  tumor  is  found 
descending  with  inspiration.  The  suppuration  is  not  always  limited 
to  the  gall-bladder.  Marked  leucocytosis  points  to  the  gall-bladder 
lesion  being  suppurative.  Acute  phlegmonous  cholecystitis — the 
acute  progressive  empyema  of  Courvoisier — runs  generally  a  very 
rapid  course,  and  leads  to  death  by  general  peritonitis,  with  which  it 
is  apt  to  be  confounded.  The  action  of  the  bowels  is  paralyzed,  and 
intestinal  obstruction  is  thus  closely  simulated."  Phlegmonous  chole- 
cystitis may  lead  to  perforation  of  the  gall-bladder  with  symptoms  of 
collapse. 

^  Diseases  of  the  Gail-Bladder  and  Bile-Ducts,  1897. 

^  Acute  Inflammation  of  the  Gall-Bladder,  Amer.  Journ.  Med.  Sci.,  June,  1898. 
•*  See  case  of  Arbuthnot  Lane,   Lancet,   Feb.   1893,    in  which  there  was  an 
operation  followed  by  recovery. 


582  MEDICAL  DIAGNOSIS. 

Acute  Cholangitis. — Inflammation  of  the  bile-ducts  may  be 
associated  with  any  of  the  forms  of  inflammation  of  the  gall-bladder, 
or  exist  without  it.  Most  commonly  it  is  of  infective  origin,  due  to 
gall-stones  in  the  common  duct,  or  to  influenza,  or  to  the  bacillary 
infection  of  typhoid  fever.  There  is  general  tenderness  of  the  liver 
with  or  without  pain,  enlargement  of  the  liver,  and  an  irregular  fever 
which  takes  the  form  of  hepatic  fever ;  and  usually  a  persistent,  slight 
icterus  between  the  marked  attacks.  The  disease  may  continue  for  a 
long  time,  and  in  the  suppurative  form  is  generally  subacute  in  its 
course.  There  is  in  this  great  loss  of  strength,  anaemia,  and  marked 
emaciation ;  and  a  septic  endocarditis,  or  pleurisy  or  pneumonia  may 
lead  to  death. 

Acute  Diseases  characterized,  by  a  Decrease  in  the  Size  of 
the  Liver  and  by  Deep  Jaundice. 

Acute  Yellow  Atrophy. — This  dangerous  affection  consists  in 
a  rapid  diminution  of  the  liver,  with  disintegration  in  the  secreting- 
cells.  To  this  disease  belong  most  of  those  cases  of  malignant  jaun- 
dice which  terminate  rapidly  in  death  after  violent  cerebral  symptoms. 
The  malady  scarcely  ever  lasts  a  week ;  generally  a  few  days  only 
elapse  before  the  patient  becomes  comatose  and  dies. 

The  complaint  is  sometimes  ushered  in  by  nausea,  a  coated  tongue, 
irregular  action  of  the  bowels,  and  a  frequent  pulse ;  at  other  times 
it  begins  abruptly  with  pain  in  the  head,  and  with  vomiting,  at  first  of 
the  contents  of  the  stomach,  but  soon  of  coffee-ground  material,  which 
is  evidently  altered  blood.  The  skin  is  yellow,  and  becomes  from 
hour  to  hour  more  discolored.  Jaundice  is,  indeed,  never  absent :  it 
may  not  make  its  appearance  before  the  other  urgent  symptoms,  but 
sometimes  it  precedes  the  signs  of  serious  difficulty  for  several  days, 
or  even  for  longer, — perhaps  for  upward  of  two  weeks.^  That  the 
jaundice  is  not  due  to  obstruction  is  proved  by  the  stools  containing 
bile.  There  are  not  uncommonly  pain  at  the  epigastrium  and  in  the 
hepatic  region,  vomiting,  muscular  and  arthritic  pains,  dyspnoea, 
meteorism,  enlargement  of  the  spleen,  epistaxis,  and  hemorrhage  from 
the  bowels.  The  pulse  exhibits  extraordinary  changes:  it  is  gener- 
ally very  rapid,  but  sinks  at  times,  without  any  assignable  reason,  to  a 
normal  frequency  ;  during  the  deep  coma  of  the  last  stages  of  the 
malady  the  beat  of  the  artery  is  apt  to  become  slow  and  full,  but  it 
may  be  quick  and  small.  There  is  fever,  not,  however,  active ;  the 
temperature   may  be,  indeed,  after  the  early  stages  of  the  disease. 


1  As  in  Observation  No.  XVII.  of  Frerichs  on  Diseases  of  the  Liver. 


DISEASES  OF  THE  LIVER.  583 

below  the  norm  until  towards  the  end,  when  it  has  been  known  to 
be  104°  or  105°.  The  surface  may  be  covered  with  petechiee.  But, 
if  we  except  the  deep  jaundice  and  the  lessening  hepatic  dulness, 
the  most  significant  symptoms  are  those  referable  to  the  nervous 
system.  Severe  headache,  delirium,  involuntary  discharges,  tremors, 
spasms,  convulsions,  or  a  constantly  increasing  stupor  with  sluggish 
pupils,  show  clearly  what  disturbance  the  poisoned  blood  is  creating 
in  the  nervous  centres. 

Acute  atrophy  of  the  liver  rarely  happens  in  children  or  after 
forty  years  of  age  ;  it  is  much  more  common  in  women  than  in  men. 
We  find  it  not  unusually  following  violent  mental  emotions  or  drunk- 
enness and  venereal  excesses  ;  or  it  occurs  during  pregnancy,  and  is 
then  accompanied  by  renal  disorder. 

In  point  of  diagnosis  we  have  chiefly  to  consider  the  distinction 
from  yellow  fever,  and  from  such  diseases  as  typhoid  fever,  peritonitis, 
pneumonia,  and  meningitis,  when  accompanied  by  jaundice  and  de- 
lirium. The  character  of  the  eruption,  the  presence  of  diarrhoea 
instead  of  constipation,  the  milder  nature  of  the  mental  wandering, 
the  significant  temperature  record,  the  slight  icterus,  the  Widal  reac- 
tion, and  the  slower  progress  of  the  disease  are  of  much  value  in 
enabling  us  to  distinguish  between  typhoid  fever  and  the  typhoid  symp- 
toms of  acute  yellow  atrophy  of  the  liver.'  From  yellow  fever,  acute 
atrophy  differs  by  the  epidemic  character  of  the  former,  by  the  in- 
jected eye,  by  the  intense  pain  in  the  back,  limbs,  and  forehead,  by 
the  stages  the  febrile  malady  presents,  by  the  decided  fever  tempera- 
ture, by  the  usual  presence  of  markedly  albuminous  urine,  by  the 
comparative  absence  of  cerebral  symptoms,  and  by  the  enlargement 
rather  than  the  lessened  size  of  the  liver. 

From  the  other  affections  named,  the  hepatic  disorder  may  be 
discriminated  by  a  thorough  examination  of  the  various  organs  of  the 
body,  and  by  a  careful  weighing  of  all  the  symptoms.  In  truth,  it  is 
thus  only  that  we  can  avoid  error ;  since,  unless  we  can  establish  the 
most  positive  sign  of  acute  atrophy,  the  diminution  of  the  area  of  per- 
cussion dulness  of  the  liver, — and  there  are  cases  in  which  we  cannot 
establish  this,  particularly  if  there  have  been  enlargement  from  pre- 
vious disease,^ — there  is  no  manifestation  of  the  hepatic  malady  that 
may  not  occur  in  the  diseases  mentioned,  when  they  are  complicated 
by  jaundice.  It  is  true  that  vomiting  of  blood  is  scarcely  among  their 
symptoms  ;  but  this  does  not  invariably  happen  in  acute  atrophy.  In 
cases  of  doubt  we  may  be  influenced  by  the  presence  of  tyrosine  and 

^  As  in  a  case  in  my  ward  at  the  Pennsylvania  Hospital. 


584  MEDICAL  DIAGNOSIS. 

leucine  in  the  urine ;  and  by  the  test  for  urea,  which  is  greatly  re- 
duced or  absent.  So  may  be  the  uric  acid,  the  chlorides,  the  sulphates, 
and  the  earthy  phosphates.  We  may  in  this  connection  remark 
that  leucine  and  tyrosine  have  been  also  found  in  the  blood  and  in 
many  tissues.  This  was  observed  in  a  case  which  I  saw  with  Dr.  H, 
C.  Wood,  and  which  he  has  carefully  reported.^  On  the  other  hand, 
one  or  both  may  be  wanting  in  undoubted  cases  of  acute  atrophy. 
Tube-casts  and  small  quantities  of  albumin  are  not  uncommon. 

An  affection  like  acute  yellow  atrophy  occurs  from  phosphorus 
poisoning ;  and  indeed  there  are  those  who  believe  that  acute  yellow 
atrophy  is  really  due  to  phosphorus  accidentally  introduced  into  the 
system.^  The  occurrence  of  the  fatal  malady  in  pregnant  women  has 
already  been  referred  to.  Jaundice  from  mental  emotion,  or  produced 
by  the  pressure  of  the  gravid  womb,  is  in  them  not  unusual ;  and  we 
may  be  called  upon  to  distinguish  this  harmless  form  of  icterus  from 
that  of  yellow  atrophy.  In  the  serious  derangement  of  the  nervous 
system,  and  the  graver  character  of  all  the  symptoms,  lie  the  marks 
of  separation. 

Chronic  Diseases  attended  with  Enlargement  of  the  Liver, 
and  with  shght  or  no  Jaundice. 

Chronic  Congestion. — This  morbid  condition  is  observed  chiefly 
in  persons  of  sedentary  habits,  or  in  those  who  indulge  too  freely  in 
the  pleasures  of  the  table,  or  use  large  quantities  of  alcoholic  drinks 
or  fermented  liquors.  It  is  frequently  met  with  in  hot  climates  and 
in  malarial  districts.  It  may  also  occur  in  scurv}'',  and  in  connection 
with  abdominal  affections  vdiich  interfere  with  the  portal  circulation, 
or  it  may  happen  in  consequence  of  a  disturbance  of  the  flow  of 
blood  through  the  liver,  dependent  upon  disease  of  the  heart. 

Whatever  the  source  of  the  hypereemia,  the  symptoms  are  similar. 
They  are  impaired  appetite,  bitter  taste  in  the  mouth,  a  coated 
tongue,  flatulency,  a  feeling  of  tension  and  weight  in  the  right  hypo- 
chondrium,  depression  of  spirits,  loss  of  strength,  impoverishment  of 
blood,  deposits  of  lithates  from  the  highly  colored  urine,  headache, 
dry  cough,  and  occasional  nausea  and  diarrhoea,  or  looseness  of  the 
bowels  alternating  with  constipation,  and,  in  protracted  cases,  hemor- 
rhoids.     The   conjunctiva  has    constantly  a  more  or  less  jaundiced 

^  Amer.  Journ.  Med.  Sci.,  April,  1867. 

^  Peris,  Handb.  d.  Allg.  Pathol.,  i.,  points  out  an  anatomical  distinction;  in 
acute  atrophy  there  is  fatty  degeneration  ;  in  phosphorus  poisoning  the  liver-cells 
are  only  infiltrated  with  fat. 


DISEASES  OF  THE  LIVER.  585 

tinge  ;  the  dulness  on  percussion  in  the  hepatic  region  is  increased  in 
extent ;  at  times  the  enlarged  hver  pulsates.  In  some  cases  the 
habitual  congestion  leads  to  an  altered  condition  of  the  bile-ducts  and 
of  the  secreting-cells  of  the  liver ;  but  ordinarily,  unless  the  hyper- 
semia  be  kept  up  by  some  exciting  cause  which  it  is  impossible  to 
remedy, — such  as  an  abdominal  tumor,  or  an  organic  affection  of  the 
heart, — it  can  be  removed.  A  troublesome  feature  of  the  malady  is 
its  disposition  to  return. 

Chronic  hepatic  congestion  is  sometimes  confounded  with,  or 
rather  there  is  mistaken  for  it,  a  liver  which  has  been  pushed  down- 
ward by  the  habit  of  tight  lacing.  But  the  absence  of  any  signs  of 
hepatic  derangement,  and  the  lowered  outline  of  the  upper  border  of 
the  displaced  right  lobe,  enable  us  to  distinguish  this  state. 

Chronic  hepatic  congestion,  as  indeed  any  disease  of  the  liver 
which  leads  to  its  enlargement,  may  be  confounded  with  chronic  gas- 
tric catarrh.  But  the  outline  of  the  dulness  when  the  liver  is  increased 
in  size,  the  jaundiced  hue  of  the  conjunctiva,  the  altered  character  of 
the  stools,  and  the  less  marked  gastric  symptoms  will  enable  us  to 
arrive  at  a  correct  diagnosis.  Yet  we  must  not  forget  that  the  two 
morbid  states  are  often  conjoined. 

Hypertrophy  of  the  liver  may  present  the  manifestations  of  con- 
gestion. The  little  we  know  of  an  increased  formation  of  the  liver- 
cells  teaches  us  that  this  may  happen  as  a  partial  hypertrophy,  to 
compensate  for  loss  of  substance,  in  instances  in  which  a  portion  of 
the  gland  has  been  destroyed  ;  or,  as  a  more  general  increased  growth, 
in  diabetes,  in  leukaemia,  and  as  a  consequence  of  malaria.  Yet  there 
is  never  any  certainty  in  the  diagnosis. 

So-called  torpjor  of  the  liver.,  in  which  there  is  supposed  to  be  a 
deficient  excretion  of  bile,  has  much  the  same  symptoms  as  conges- 
tion. In  persons  of  middle  life  who  eat  freely  and  take  too  little 
exercise  in  the  open  air,  or  those  of  sedentary  habits  in  whom  anxiety 
and  worry  have  lowered  the  nervous  tone,  the  well-known  symp- 
toms of  headache,  languor,  depression  of  spirits,  loss  of  appetite, 
drowsiness  after  meals,  sallow  hue  of  skin,  dingy  conjunctiva,  urine 
depositing  lithates,  stools  black  and  offensive,  or  more  often  pale  or 
whitish,  bespeak  this  "  bilious"  state,  and  we  can  only  distinguish  the 
functional  disorder  from  the  ordinary  forms  of  chronic  congestion  by 
the  history,  the  concurrent  symptoms,  and  the  enlargement  of  the 
organ,  which  these  present. 

The  symptoms  of  chronic  congestion  of  the  liver,  as  of  other 
hepatic  derangements,  show  themselves  at  times  more  particularly  in 
the  nervous  system.     Headache,  vertigo,  dimness  of  sight,  and  noises 


586  MEDICAL  DIAGNOSIS. 

in  the  ears  are  common ;  and  tingling  and  prickling  sensations  and  a 
feeling  of  creeping  in  the  extremities  may  cause  needless  fear  that 
paralysis  is  imminent,  and  disappear  under  a  mercurial  and  a  few 
saline  purgatives.  On  the  other  hand,  signs  of  stomach  and  liver 
derangement  may  be  really  due  to  an  affection  of  the  nervous  sys- 
tem. Twice  it  has  come  under  my  observation  that  altered  character 
of  the  stools,  bitter  taste  in  the  mouth,  vomiting,  and  shght  discolor- 
ation of  the  conjunctiva,  existing  in  connection  with  tumors  at  the 
base  of  the  brain,  were  considered  as  purely  of  hepatic  origin.  Clif- 
ford Allbutt^  cites  a  case  of  Meniere's  disease,  in  a  physician,  where 
the  vomiting  and  giddiness  were  thus  wrongly  accounted  for.  In  such 
instances,  the  disordered  gait,  persistent  noises  in  one  or  both  ears^ 
and  the  loss  of  power  of  hearing  of  one  ear,  shown  when  a  tuning- 
fork  is  placed  in  contact  Avith  the  skull  on  the  affected  side,  tell  the 
true  meaning  of  the  other  symptoms. 

Chronic  Hepatitis. — It  is  difficult  to  say  what  are  the  symptoms 
of  the  malady,  because  most  of  the  chronic  affections  of  the  organ, 
especially  the  congested,  the  fatty,  the  albuminoid  liver,  and  hyper- 
trophic cirrhosis  have  been  included  in  its  description.  The  liver  is 
enlarged  in  size.  The  inflammation  may  be  chronic  almost  from  its 
onset,  and  be  developed  under  much  the  same  circumstances  as  chronic 
congestion  ;  or  it  may  succeed  to  acute  hepatitis.  But  chronic  hepa- 
titis is  not  a  common  disease,  and  is  scarcely  to  be  distinguished  from 
persistent  hypersemia  of  the  organ,  unless,  as  so  often  in  tropical  hep- 
atitis, abscess  result. 

Abscess  of  the  Liver. — In  temperate  climates  we  seldom  en- 
counter this  affection,  save  as  the  consequence  of  an  embolic  or  pyeemic 
process  in  the  liver,  or  in  connection  with  some  disease  of  the  intes- 
tines, or  of  abscesses  around  the  rectum,  or  as  a  sequel  of  gastric 
ulcer,  or  of  pylephlebitis,  or  of  gall-stones  which  have  produced  ulcer- 
ation of  the  gall-bladder  and  gall-ducts  and  secondary  abscesses  of 
the  liver,  or  of  traumatism,  or  of  suppurative  disease  of  bones.  In 
hot  climates  it  is  not  an  unusual  disease,  both  in  connection  with  dys- 
entery and  without  it. 

The  symptoms  of  hepatic  abscess  are  obscure.  Sometimes  the 
only  symptoms  are  debility,  great  irritability  of  the  nervous  system, 
and  irregular  slight  febrile  attacks.  More  usually  the  formation  of 
pus  gives  rise  to  rigors,  leads  to  night-sweats,  and  not  infrequently  to 
the  development  of  a  fever  simulating  that  of  a  quotidian  or  tertian 
intermittent  or  remittent,  and  attended  during  certain  hours  of  the 

^  St.  George's  Hosp.  Rep.,  vol.  viii. 


DISEASES  OF  THE  LIVER.  587 

day  with  considerable  elevation  of  temperature.  Jaundice  occurs,  but 
is  generally  slight,  and  is  often  absent.  There  'is  no  enlargement  of 
the  abdominal  veins,  nor  is  there,  save  exceptionally,  ascites  or  oedema 
of  the  lower  extremities.  Dry  cough,  quickened  breathing,  and  gas- 
tric disorder,  especially  loss  of  appetite,  are  frequent,  and  obstinate 
vomiting,  hiccough,  and  meteorism  are  not  unusual.  There  is  always 
marked  leucocytosis.  In  the  advanced  stages  of  the  malady  typhoid 
symptoms  are  apt  to  develop.  But  the  disease  may  be  latent.  The 
local  signs,  too,  are  far  from  being  always  obvious,  or  indeed  uniform. 
In  some  instances  the  hepatic  region  is  more  prominent  than  natural, 
and  we  can  detect  fluctuation  over  portions  of  the  enlarged  gland ; 
but  neither  sign  is  constant,  and  the  latter  depends  greatly  upon 
whether  or  not  the  abscess  is  deeply  seated.  Tenderness,  either  gen- 
eral or  limited,  is  found  only  in  a  certain  proportion  of  cases,  espe- 
cially when  the  abscess  is  near  the  surface.  It  is  frequently  associ- 
ated with  a  throbbing  or  a  dull  pain,  which  may  be  transmitted  to  the 
right  shoulder.  According  to  Annesley,^  this  sympathetic  pain  in  the 
right  shoulder  indicates  that  the  convex  part  of  the  right  lobe  of  the 
viscus  is  affected.  Conjoined  to  the  feeling  of  weight,  and  to  the 
throbbing  in  the  hepatic  region,  is  at  times  a  tension  occasioned  by  pal- 
pation of  the  abdominal  muscles,  especiahy  of  the  rectus.  Twining^ 
regards  this  as  very  significant  of  deep-seated  abscess.  The  pain  of 
hepatic  abscess  may  be  acute,  like  that  of  an  intercostal  neuralgia, 
and  greatly  aggravated  by  cough.^  Cyr*  tells  us,  with  reference  to 
the  exact  position  of  the  abscess,  that  when  it  is  in  the  front  convex 
part  of  the  liver  there  is  pain  radiating  to  the  chest  and  shoulder, 
dyspnoea,  but  rarely  jaundice ;  when  in  the  central  part  of  the  organ^ 
there  are  few  signs  of  local  affection  of  the  liver  itself  or  adjacent 
organs,  except  decided  jaundice  if  the  abscess  be  large.  In  abscess 
limited  to  the  under  surface,  thoracic  symptoms  are  absent,  but  gas- 
tric symptoms,  especially  uncontrollable  vomiting,  occur ;  the  pain  is 
apt  to  radiate  towards  the  groin. 

A  positive  diagnosis  of  abscess  of  the  liver  is  often  a  very  difficult 
matter ;  for  there  are  a  number  of  affections  with  which  it  may  be 
readily  confounded.  Prominent  among  these  are  hydatids,  cancer  of 
the  liver,  actinomycosis  of  the  liver,  affections  of  the  gall-bladder,  and 
a  pleuritic  effusion  on  the  right  side. 

From  hydatids  of  the  liver,  the  febrile  symptoms,  the  disturbed 

^  Researches  into  the  Diseases  of  India.  ^  Diseases  of  Bengal. 

'  Malbot,  Abces  du  foie  en  Algerie,  Arch.  Gen.  de  Med.,  Aug.  1899. 
*  Traite  des  Maladies  du  Foie,  1887. 


588  MEDICAL   DIAGNOSIS. 

nutrition,  and  the  pain  distingmsli  an  hepatic  abscess,  except  m  tliose 
cases  in  whicli  tlie  cyst  becomes  tlie  seat  of  suppuration.  Under  these 
circumstances  error  can  scarcely  be  avoided,  unless  we  are  fully  cog- 
nizant of  the  previous  liistory. 

Cancer  of  the  liver  differs  from  an  abscess  by  its  dissimilar  liis- 
tor}^,  by  the  hard  nodular  masses,  and  by  the  absence  of  fluctuation. 
It  is  only  in  rapidly  growing  medullar}^  cancer  that  we  can  discern  a 
sense  of  fluctuation ;  but  even  here  we  can  generally  distinguish 
some  nodules  which  do  not  fluctuate.  Further,  the  marked  fever 
and  the  other  constitutional  symptoms  are  not  like  what  occur  in 
hepatic  cancer ;  for  in  this  affection,  as  in  all  cancers,  the  tempera- 
ture, except  in  instances  of  large,  rapidly  spreading  gro^vths,  is  but 
little  affected, — may.  indeed,  be  subnormal. 

Actinomycosis  of  the  liver  may  give  rise  to  a  collection  of  pus,  and 
the  abscess  may  discharge  through  the  loins  or  through  the  lungs,  as 
in  hepatic  abscess-.  The  hepatic  swellmg  is  painful  on  pressure,  but 
is  unlike  that  of  hepatic  abscess  in  arising  suddenly  from  the  parts 
beneath,  and  in  being  surrounded  by  a  Arm  base  in  the  liver.  These 
characters  distinguish  it  from  an  ordinary  abscess  as  well  as  from 
hydatid  of  the  liver.^  Yet  it  is  by  the  history,  and  by  finding  the  ray 
fungus  in  pus  from  other  diseased  parts  of  the  body,  that  the  diag- 
nosis is  mostly  established,  for  actinomycosis  of  the  liver  is  almost 
never  prunary. 

Of  the  affections  of  the  gall-bladder^  the  one  most  liable  to  be  con- 
founded ^^ith  hepatic  abscess  is  distention.  This  occurs  either  from 
a  closure  of  the  cystic  or  of  the  common  duct,  especially  the  former, 
or  fi:"om  cholecystitis,  with  perhaps  a  subsequent  closure  of  the  ducts. 
In  such  a  case  the  gall-bladder  may  become  enormously  distended 
with  decomposing  bile  and  puriform  matter,  and  thus  may  be  occa- 
sioned a  fluctuating  tumor,  tender  on  pressure,  and  readily  mistaken 
for  an  abscess.  Now,  we  are  sometimes  able  to  distinguish  the  soft 
swehing  caused  by  a  diseased  gall-bladder  by  its  situation,  its  pear- 
shaped  form,  its  mobility,  its  distinct  and  persistent  fluctuation ;  by 
the  normal  appearance  of  the  parietes  of  the  abdomen ;  by  the  ten- 
derness over  the  tumor  and  absence  of  tenderness  over  the  liver; 
and  by  the  fact  that  affections  of  the  gall-bladder  are  frequently  pre- 
ceded by  repeated  attacks  of  violent  pain  due  to  the  passage  of  biliary 
calculi.  Then  we  find  little  jaundice,  or  none  at  all ;  and  no  hectic 
fever.  But  to  neither  of  these  circumstances  can  we  trust  implicitly. 
For  there  is  apt  to  be  intense  jaundice  in  an  aftection  of  the  gall- 

^  Harley,  Med.  Chir.  Transact.,  vol.  Ixix.,  1886. 


DISEASES  OF  THE  LIVEE.  589 

bladder,  if  the  common  duct  also  be  implicated ;  and  jaundice  is,  in 
abscess  of  the  liver,  a  symptom  more  frequently  absent  than  present. 
And  ^vith  reference  to  hectic  fever,  the  continued  suppuration  in  the 
distending  sac  may  produce  it,  and  lead,  indeed,  to  great  constitu- 
tional disturbance.^  Further,  these  biliary  abscesses  may,  like  hepatic 
abscesses,  open  externally,  or  burst  into  the  chest.  At  times  the 
communication  is  with  the  bronchial  tubes,  and  gives  rise  to  very 
anomalous  symptoms.  Thus,  Simmons  ^  details  a  case  m  which  there 
was  a  tumor  in  the  epigastrium,  fluctuating,  with  a  sense  of  inter-- 
vening  air  or  gas,  and  resonant  on  percussion ;  a  blowing  somid  was 
distinctly  discerned  synchronous  with  the  respiratory  act,  and  occa- 
sionally accompanied  by  a  gurgling  noise ;  there  were  no  signs  of 
pneumothorax.  At  the  autopsy  a  biliary  abscess  was  found  com- 
municating with  the  right  bronchus. 

A  j^^uritie  effusion  on  the  right  side  is  distinguished  from  an 
hepatic  abscess  by  the  physical  signs  of  the  effusion.  But  abscesses  of 
the  liver  may  open  into  the  right  pleural  cavity.  Then  we  observe 
the  physical  signs  of  a  pleuritic  effusion  subsequent  to  those  of  hepatic 
abscess.  Finally,  it  generally  happens  that  large  quantities  of  puru- 
lent sputa  are  expectorated ;  in  rarer  instances  the  pus  is  discharged 
through  the  walls  of  the  chest.  In  the  former  case,  the  accumulation 
of  pus  in  the  pleura  may  be  limited ;  the  inflammation  of  the  pleural 
membrane  may  be  circumscribed,  while  the  signs  of  an  inflammation 
at  the  lower  portion  of  the  right  lung,  dulness  on  percussion,  tubular 
breathing,  and  rusty-colored  sputa,  are  evident.  These  phenomena 
may  subside,  and  the  respiration  in  parts  become  inaudible,  when  a 
discharge  of  a  large  quantity  of  a  reddish  or  whitish  pus  takes  place, 
in  which  the  elements  of  bile  and  the  microscopical  appearances  of  the 
hepatic  tissue  may  be  detected.  Gradually  this  expectoration  ceases, 
and  the  affected  textures  heal.  But  in  some  instances  the  discharge 
never  stops,  and  the  patient  dies  worn  out  by  the  constant  drain. 

In  subphrenic  jieritonitis  the  exudate  may  occasion  a  swelling  and 
lead  to  an  abscess  producing  misleading  symptoms.  The  tumor 
shows  itself  chiefly  in  the  left  hypochondrium  or  the  epigastrium, 
and  seems  to  disappear  when  the  stomach  is  distended  with  gas,  and 
to  increase  when  the  stomach  is  full ;  the  colon  always  lies  below  the 
tumor.  The  constitutional  symptoms  are  those  of  suppuration ;  the 
chills  and  irregular  fever  may  be  very  marked  symptoms ;  there  is 

^  As  in  a  case  reported  by  Pepper,  the  elder,  Amer.  Journ.  Med.  Sci.,  Jan, 
1857. 

^  Amer.  Journ.  Med.  Sci.,  Oct.  1877. 

37 


590  MEDICAL  DIAGNOSIS. 

much  pain,  Tomiting,  and  embarrassed  breathing.  The  mbphrenic 
abscesses  develop  generally  as  the  result  of  perforation  of  a  gastric  or 
duodenal  ulcer.  They  are  very  apt  to  be  mistaken  for  abscess  of  the 
liver,  and,  except  by  their  history  and  the  characters  mentioned,  cannot 
be  discriminated.  These  too,  chiefly  distinguish  them,  when  they  also 
press  upward,  from  a  collection  of  fluid  in  the  right  pleural  sac.  They 
often  contain  air,  extend  into  the  thorax,  and  we  then  have  devel- 
oped that  curious  condition  described  as  subphrenic  pyojmeumothorax, 
*  which,  when  on  the  right  side,  is,  except  for  the  physical  signs,  easUy 
mistaken  for  the  breaking  of  an  hepatic  abscess  into  the  chest.  The 
historj^  of  the  affection  is  generally  significant ;  the  subphrenic  abscess 
itself  is  the  result  of  a  perforating  ulcer  of  the  stomach  or  of  the  duo- 
denum, occasionally  of  an  appendicitis,  and  at  times  is  preceded  by 
the  symptoms  of  a  general  or  local  peritonitis  or  by  the  discharge  of 
pus  from  the  bowels,  and  it  sets  in  abruptly  with  pam  and  vomiting 
of  bilious  or  bloody  kind.  The  tumor  formed  by  the  subphrenic 
abscess  has  the  characters  just  described.  The  signs  of  pneumo- 
thorax subsequently  show  themselves,  as  Leyden^  has  found,  with 
distinct  metallic  tinkling  and  succussion  sound.  Yet,  while  all  breath- 
sound  is  sharply  cut  off  below  the  fourth  or  fifth  rib,  up  to  this  point 
the  normal  vesicular  murmur  is  heard  on  deep  respiration,  and  there 
are  no  signs  of  pressure  in  the  pleural  canity  or  of  distention  of  the 
chest ;  and  the  marked  alteration,  by  change  of  position,  of  the  dulness 
on  percussion,  from  the  exudation  at  the  lower  part  of  the  chest,  is 
strictly  limited  to  this  part.  The  liver  reaches  to  the  umbilicus  or 
lower,  and  when  a  canula  is  passed  into  the  cavity  beneath  the  dia- 
phragm and  a  manometer  is  attached,  inspiration  shows  increased 
pressure,  expiration  the  reverse, — exactly  opposite,  therefore,  to  what 
happens  if  the  canula  be  in  the  pleura. 

When  an  hepatic  abscess  forces  its  way  externally,  it  may,  prior 
to  its  discharge  through  the  thoracic  or  abdominal  walls,  occasion 
difficulty  in  diagnosis  from  abscesses  originating  in  these  walls. 
Nothing  but  a  careful  consideration  of  the  attending  symptoms  and  of 
the  histor)-  of  the  case  will  lead  to  a  differential  distinction.  Xor 
does  the  difficulty  wholly  cease  when  the  slowly  developed  tumor, 
which  an  hepatic  abscess  forms,  has  opened ;  since  it  is  far  from 
always  that  we  find  in  the  pus  the  e\ddences  of  the  broken-down 
liver-tissue,  and  it  is  only  occasionally  that  the  fluid  is  of  yellow  or 
greenish  color  and  yields  the  reactions  of  bile.  The  means  of  dis- 
crimination most  to  be  relied  upon  is  a  probe  ;  for  by  the  depth  to 

1  Zeitschrift  fiir  klin.  Med.,  Bd.  i. 


DISEASES  OF  THE  LIVER.  59I 

which  it  can  be  passed,  the  direction  it  takes,  and  the  feel  of  the 
structures  it  encounters,  we  are  placed  in  possession  of  many  impor- 
tant facts.  In  doubtful  cases,  also,  we  employ  the  aspirator,  and  a 
chemical  and  microscopical  examination  of  the  pus,  other  than  that 
oozing  out  of  the  opening,  may  tell  the  nature  of  the  abscess.  In- 
deed, the  aspirator  may  be  made  a  means  of  diagnosis  of  abscess  of 
the  liver  under  some  of  the  circumstances  above  mentioned,  where 
abscess  is  closely  simulated  by  other  hepatic  affections.  No  harm 
results  from  the  exploration,  even  if  no  abscess  be  found. 

Occasionally  a  hernia  through  one  of  the  recti  muscles  is  mistaken 
for  a  projecting  abscess  of  the  liver.  I  was  called  some  years  since 
to  see  such  a  case,  in  which  the  opinion  that  it  was  an  abscess  of  the 
liver  had  been  long  entertained.  The  sound  of  the  mass  on  percus- 
sion ;  the  clearly  defined  limits  of  the  liver ;  the  absence  of  hepatic 
and  gastric  symptoms, — taught  the  true  nature  of  the  malady. 

Much  has  been  said  of  the  distinction  between  the  abscesses  which 
are  developed  in  the  course  of  embolism  or  of  pygemia,  "  the  pyaemic 
abscess,"  and  the  abscess,  common  in  tropical  climates,  which  forms 
as  the  result  of  hepatitis,  "  the  tropical  abscess."  This  kind  of  abscess 
is  often  met  with  following  dysentery.  One  of  its  forms  occurs  in 
connection  with  the  amoeba  coli,  though  we  may  have  abscess  of  the 
liver  due  to  the  amoeba  without  dysenteric  symptoms,  and  tropical 
abscess  irrespective  of  any  kind  of  dysentery.  There  is  first  a  patho- 
logical change  in  the  liver,  and  then,  it  is  supposed,  a  microbic  infec- 
tion.^ The  points  of  distinction  between  pyaemic  and  tropical  abscess 
may  be  thus  tabulated  : 

PYiEMic  Abscess.  Tropical  Abscess. 

Many  in  number ;  small  in  size.  Usually  a  single  large  abscess,  seated  in 

right   lobe,   towards   the  convexity  of 
the  liver. 
Uniform  enlargement  of  liver ;  only  ex-     Enlargement   not   uniform  ;    bulging   of 
ceptionally  bulging  of  ribs.  ribs,    or  in   epigastrium,   or  in   right 

hypochondrium. 
No  fluctuation  ;  always  pain  and  tender-     Fluctuation  usual ;  pain  and  tenderness 

ness.  always  absent. 

Jaundice    present    in    the    majority    of    Jaundice  exceptional. 

cases. 
Enlargement  of  spleen  usual.  Enlargement  of  spleen  unusual. 

Rigors  and  night-sweats  marked  ;  often     Rigors  and   night-sweats   less    marked  ; 
symptoms  of  blood-poisoning.  obstinate  vomiting  often  present. 

^Davidson,   article   "Suppurative  Hepatitis,"  Allbutt's   System  of  Medicine, 
vol.  iv. 


592  MEDICAL  DIAGNOSIS. 

Pyemic   Abscess.  Tropical   Abscess. 

Course    rapid  ;    three    weeks    to    three  Course  less  rapid  ;  often  extends  to  three 

months.  or  six  months,  or  longer. 

Arises  after  external  injuries  and  opera-  Arises   in   tropical   climates,    chiefly   in 

tions,  or  suppurating  cavities,  or  ulcer-  those  who  eat  and  drink  largely  ;  dys- 

ations,  such  as  ulcers  of  the  stomach  entery  frequently  coexists, 
or  gall-bladder. 

Fatty  Liver. — A  fatty  liver  occurs  in  drunkards ;  in  obese  per- 
sons ;  in  wasting  diseases,  especially  in  phthisis ;  in  the  course  of 
protracted  diarrhoea,  and  sometimes  in  children  after  exanthematous 
fevers. 

A  knowledge  of  the  sources  of  fatty  liver  is  the  most  important 
element  in  the  diagnosis ;  for  neither  the  physical  signs  nor  the 
symptoms  present  anything  which  is  characteristic.  The  physical 
signs  are  simply  those  of  an  enlarged  painless  liver ;  the  enlargement 
is  generally  moderate  and  uniform,  and  the  lower  margin  rounded. 
The  symptoms  are  much  the  same  as  those  of  hepatic  congestion, 
except  that  there  is  perhaps  greater  tendency  to  diarrhoea.  There  is 
no  ascites  ;  the  amount  of  jaundice  is  always  very  slight ;  in  truth, 
jaundice  is  most  frequently  wanting. 

Waxy  Liver. — This  peculiar  degeneration  of  the  liver  which 
forms  part  of  a  general  cachexia  manifests  itself  rather  by  the  signs 
of  disturbance  of  other  organs  than  by  the  direct  proof  of  altered 
function  of  the  viscus  affected.  Thus,  disordered  digestion,  nausea, 
vomiting,  tympanites,  discolored  stools,  and  diarrhoea  are  much  more 
frequent  than  jaundice,  which,  indeed,  is  very  much  oftener  absent 
than  present.  There  is  a  feeling  of  fulness  in  the  hepatic  region,  but 
no  pain ;  while  physical  exploration  exhibits  an  increased  percussion 
dulness,  and  shows  the  dense  organ  to  have  a  well-defined  though 
somewhat  rounded  margin.  The  enlargement  is  uniform,  but  con- 
siderable ;  at  times  so  great  that  the  liver  occupies  a  large  part  of  the 
abdomen,  producing  a  visible  bulging.  The  smoothness  and  the 
regularity  of  outline  are  lost  if  waxy  liver  coexist  with  diseases  of  the 
liver  which  may  harden  the  organ  in  nodules,  such  as  cancer,  fibroid 
changes,  or  cirrhosis. 

Enlargement  of  the  spleen  is  commonly  associated  with  the 
enlargement  of  the  liver,  and  in  many  cases  the  urine  is  albumi- 
nous from  waxy  disease  of  the  kidneys.  Dropsy,  as  a  rule,  is  not 
encountered;  but  in  this  respect  much  depends  upon  the  state  of 
the  kidneys  and  of  the  blood,  or  upon  the  existence  of  secondary 
peritonitis. 


DISEASES  OF  THE  LIVER.  593 

Waxy  liver  is  much  more  common  in  males  than  in  females.  It 
is  usually  caused  by  constitutional  syphilis  or  coexists  with  scrofulous 
diseases  of  the  bones,  with  unhealed  ulcers,  especially  rectal  ulcers, 
with  long-continued  suppuration.  In  some  instances  it  is  associated 
with  cancer  or  with  phthisis,  or  malaria,  or  results  seemingly  from  the 
abuse  of  mercury.     There  is  always  a  cachexia. 

The  disease  is  one  lasting  for  years.  In  advanced  cases,  besides 
the  spleen  and  the  kidneys,  the  stomach  and  the  intestines  are  apt  to 
be  implicated ;  looseness  of  the  bowels,  with  dysenteric  symptoms 
arises,  and  the  skin  and  breath  have  a  musty,  disagreeable  odor. 

Now,  when  we  contrast  a  waxy  liver  with  other  hepatic  complaints 
in  which  the  liver  is  enlarged,  we  fmd  it  resembling  most  closely  the 
fatty  and  the  syphilitic  affections.  But  in  the  former,  although  there 
is  enlargement,  it  is  not  often  so  great  as  in  the  waxy  liver.  Besides, 
the  organ  feels  softer  on  palpation,  and  the  disorder  is  not  associated 
with  a  diseased  spleen  or  kidney,  and  is  much  less  likely  than  a  waxy 
liver  to  give  rise  to  dropsy.  Then  the  history  of  the  case  is  very  sig- 
nificant. A  syphilitic  hepatitis,  with  which  indeed  the  waxy  liver  is 
at  times  combined,  is  further  distinguished  by  the  prominent  nodules 
felt  on  the  surface  of  the  liver.  From  congestion  of  the  liver^  waxy 
liver  is  readily  discriminated.  A  comparatively  slight  affection  in 
which  jaundice  is  frequent  is  very  different  from  a  malady  in  which 
the  hepatic  disease  is  but  part  of  a  general  morbid  state  and  in  which 
jaundice  is  very  infrequent.  In  leukcemic  liver  we  may  have  consider- 
able and  smooth  enlargement,  but  the  history  of  the  case  and  an 
examination  of  the  blood  tell  its  true  nature. 

Cancer  of  the  Liver. — In  cancer  of  the  liver  the  organ  is  almost 
invariably  large,  and  sometimes  it  reaches  an  enormous  volume.  It 
is  irregular  and  uneven,  nodules  of  various  size  being  developed  in  its 
substance  and  projecting  from  its  border  and  surfaces.  These  prom- 
inences are  harder  than  the  surrounding  hepatic  tissue  ;  but  there  are 
exceptions  to  this  rule,  for  sometimes,  especially  in  the  encephaloid 
variety,  the  elastic  tumors  impart,  when  pressed,  a  very  deceptive 
sense  of  fluctuation.  The  cancerous  masses  increase,  and  in  some 
cases  with  great  rapidity. 

The  malignant  disease  is  rarely  confined  to  the  liver ;  it  frequently 
supervenes  upon  cancer  of  the  mammary  gland,  or  of  the  uterus,  or 
of  the  stomach,  or  pancreas.  It  is  an  affection  of  middle  life  or  of 
old  age ;  yet  it  occasionally  occurs  in  young  persons.  I  have  met 
with  two  cases  of  primary  cancer  of  the  liver  in  women  not  twenty- 
five  years  of  age,  and  two  in  children.  In  primary  cancer  of  the 
liver  we  generally  find  a  history  of  cancer  in  the  family ;  and  pro- 


594  MEDICAL   DIAGNOSIS. 

traded  grief  or  anxiety,  Murchison  tells  us/  may  precede  the  de- 
velopment of  the  malady,  whether  a  family  tauit  can  be  traced  or 
not.  Cancer  of  the  liver  rarely  lasts  beyond  a  year,  and  it  may  run 
a  rapid  course.  Tliis  is  especially  the  case  with  primary  cancer. 
The  proportion  of  this  to  secondary  cancer  is  stated  by  Hale  White  ^ 
as  one  to  twenty-five. 

In  the  diagnosis  of  hepatic  cancer,  the  most  important  physical 
signs  are  the  increased  percussion  dulness  m  the  hepatic  region  and 
the  uneven  surface  detected  on  palpation.  The  enlarged  liver  is  found 
extending  across  the  epigastrium  far  into  the  left  hypochondrium ;  it 
reaches  at  times  lower  than  the  umbilicus,  and  presses  the  diaphragm 
upward ;  the  line  of  dulness  moves  markedly  downward  vith  full 
inspiration.  The  nodules  can  often  be  felt  distinctly  through  the 
abdominal  walls,  and  deep  inspiration  may  reveal  a  nodule  other^^ise 
not  perceptible.  The  diseased  organ  is  painful,  and  tender  to  the 
touch.  In  cases  in  which  the  peritoneal  covering  is  affected,  the  ten- 
derness is  greatest.  And,  although  any  of  these  three  phenomena — 
the  enlargement,  the  uneven  surface,  and  the  tenderness — may  be 
absent,  they  are  tolerably  constant  attendants  on  cancer  of  the  liver. 
The  tenderness  is  rarely  wanting. 

Among  the  symptoms  of  hepatic  cancer,  we  find  gastric  and  intes- 
tinal disturbances ;  pain  in  the  right  shoulder ;  an  annoying  cough  ; 
rigidity  of  the  abdominal  muscles  ;  wasting  of  the  whole  body ;  a 
cachectic  look ;  occasional  febrile  attacks,  yet,  on  the  whole,  normal 
or  subnormal  temperature  ;  and,  in  the  later  stages,  sometimes  hemor- 
rhages from  the  stomach  or  bowels,  and  diarrhcEa.  Ascites,  too,  is 
observed,  and  is  generally  dependent  either  upon  chronic  peritonitis 
attending  the  development  of  the  cancer,  or  upon  the  pressure  this 
exerts  upon  the  larger  branches  of  the  portal  vein.  Jaundice  may  or 
may  not  be  present ;  it  is  frequently  wantmg.  I  have  seen  it  intense 
when  the  cancerous  growth  or  a  cancerous  gland  pressed  on  the  bile- 
ducts,  and  sometimes  it  is  of  a  peculiar  dark-green  color.  In  any 
instance  it  persists  until  death.  There  are  cases  in  which  all  these 
symptoms  are  perceived ;  in  others  only  some  occur,  and  in  others, 
again,  even  these  few  may  not  be  well  defined.  Indeed,  when  we 
consider  the  amount  of  deposit  which  is  generally  present ;  when  we 
regard  its  character  ;  when  we  take  into  account  the  necessarily  im- 
paired function  of  one  of-  the  most  important  glands  in  the  body ; 
when  we  reflect  upon  the  pressure  which  the  enlarged  organ  must 

^  Lectures  on  Diseases  of  the  Liver,  2d  edit. 

^  Tumors  of  the  Liver,  Allhutt's  System  of  Medicine. 


DISEASES  OF  THE  LIVER.  595 

occasion, — it  is  truly  astonishing  that  often  so  Uttle  dropsy,  so  httle 
jaundice,  so  Httle  pain,  so  little  constitutional  disturbance,  are  pro- 
duced by  the  disease. 

Yet  in  point  of  diagnosis  we  can  generally  discern  the  malady  by 
the  combination  of  the  symptoms  and  signs  indicated.  It  is  only  at 
an  early  stage  of  the  disease,  or  when  the  liver  is  not  enlarged,  that 
we  are  apt  to  be  in  doubt.  When  the  liver  is  the  seat  of  cancer,  but 
is  not  increased  in  size,  the  recognition  of  the  malady  is  next  to  im- 
possible. In  these  obscure  cases,  the  persistent  tenderness  in  the 
hepatic  region,  accompanying  the  evidences  of  disturbed  function  of 
the  liver,  ascites,  ansemia,  and  a  cachectic  appearance,  are  the  signs 
most  likely  to  lead  to  a  correct  conclusion.  In  any  instance,  jaun- 
dice coming  on  in  a  person  over  forty  years  of  age,  lasting  for  months, 
and  associated  with  gastric  disease  and  failing  health,  must,  in  the 
absence  of  a  history  of  gout  or  of  syphilis,  be  looked  upon  as  pointing 
to  hepatic  cancer,  if  we  can  exclude  cancer  of  the  pancreas.  Again, 
we  must  remember  that  loss  of  flesh  and  of  strength  often  pre- 
cedes jaundice  and  pain, — in  fact,  all  signs  of  disorder  of  the  affected 
organ. 

Let  us  pass  in  review  the  complaints  with  which  well-marked 
cancer  of  the  liver  may  be  confounded.  Omitting,  because  elsewhere 
discussed,  hydatids,  abscess  of  the  liver,  and  hypertrophic  cirrhosis, 
they  are : 

Waxy  Liver  ;  Fatty  Liver  ;  Chronic  Congestion  ; 
Acute  Congestion  ;  Acute  Hepatitis  ;  Catarrhal  Jaundice  ; 
Syphilitic  Liver  ; 
Affections  of  the  Gall-Bladder  ; 
Cancer  of  the  Stomach  ; 
Cancer  of  the  Omentum  ; 
Enlargement  of  the  Right  Kidney. 

Wavy  Liver;  Fatty  Liver;  Chronic  Congestion. — A  waxy  liver 
presents  often  as  much  increase  in  size  as  cancer ;  moreover,  like 
cancer,  it  is  associated  with  evident  signs  of  cachexia.  The  main 
points  of  distinction  are  the  smooth  surface  and  uniform  increase  of 
the  liver  in  waxy  disease,  its  painlessness  and  slow  progress,  its  com- 
bination with  enlargement  of  the  spleen  and  markedly  albuminous 
urine,  and  the  history  of  the  case  pointing  to  long-continued  suppura- 
tion, to  constitutional  syphilis,  or  to  diseases  of  the  bones,  or,  in  fe.ct, 
to  one  of  the  causes  which  generally  lie  at  the  root  of  waxy  degenera- 
tion. In  the  differentiation  of  cases  of  infiltrated  cancer  without  dis- 
tinct nodules,  the  physical  exploration  does  not  aid  us,  and  we  have 
to  lay  stress  on  the  other  points. 


596  MEDICAL  DIAGNOSIS. 

A  fatty  liver  is  easier  to  discriminate  from  hepatic  cancer.  The 
occurrence  of  the  non-mahgnant  malady  in  the  obese^  in  consump- 
tives or  in  drunkards,  and  the  total  absence  of  pain, — in  truth,  of  any 
decided  indications  of  hepatic  disease,  except  increased  size  of  the 
organ, — enable  us  to  distinguish  between  the  two  affections.  The 
slighter  signs  of  disturbance,  both  constitutional  and  local,  the  dissim- 
ilar history,  and  the  uniform  enlargement  of  the  liver  separate  chronic 
congestion  from  cancer.  As  a  mark  of  distinction,  too,  of  the  can- 
cerous from  all  of  these  non-malignant  disorders,  Virchow  lays  stress 
on  the  existence  of  swollen  jugular  glands  ;  and  a  small  cancerous 
induration  in  the  abdominal  walls,  around  the  umbilicus,  also  not 
infrequently  aids  the  diagnosis. 

Acute  Congestion;  Acute  Hepatitis;  Catarrhal  Jaundice. — It  is 
rarely  indeed  that  these  ailments  are  confounded  with  cancer  of  the 
liver,  because  the  history  and  the  course  the  latter  malady  takes  are 
so  dissimilar  to  those  of  an  acute  hepatic  disorder.  Yet  there  are 
cases  in  which  the  malignant  disease  is  either  developed  with  great 
rapidity,  thus  simulating  an  ordinary  acute  affection,  or  has  lain  dor- 
mant and  passed  unnoticed  until  it  begins  suddenly  to  increase. 
Under  such  circumstances  we  may  be  able  to  recognize  the  malignant 
complaint,  if  its  physical  phenomena  be  well  defined  ;  but  if  these  be 
not  clearly  marked,  the  diagnosis  is  one  of  great  difficulty. 

To  cite  a  case  in  illustration :  A  married  woman,  twenty-five  years 
of  age,  was  admitted  into  the  Philadelphia  Hospital  on  January  14, 
1862,  with  jaundice  and  shght  fever.  She  stated  that  she  had  been 
in  excellent  health  until  about  two  weeks  before,  when  she  caught 
cold  by  sleeping  in  a  damp  apartment.  Her  appetite  and  digestion 
had  been  good  previous  to  her  present  illness,  and  she  had  been  fully 
able  to  perform  her  household  work.  Since  she  was  taken  ill  she  had 
noticed  a  feeling  of  Aveight  in  the  region  of  the  stomach  and  liver. 
Rales  indicative  of  bronchitis  were  found  in  the  chest,  and  the  impulse 
of  the  heart  was  feeble.  The  hepatic  percussion  dulness  was  some- 
what increased  in  extent,  especially  that  of  the  left  lobe  ;  but  the 
outline  of  the  organ  appeared  regular  and  even.  Tenderness  of  the 
abdomen,  more  particularly  in  the  epigastrium  and  right  hypochon- 
drium,  was  also  noted.  There  was  nausea,  but  no  vomiting ;  the 
tongue  was  clean ;  the  evacuations  were  discolored.  Now,  here  was 
certainly  a  patient  presenting  none  of  the  signs  of  hepatic  cancer, 
except,  perhaps,  the  tenderness  over  the  enlarged  gland.  Yet  at  the 
autopsy,  which  was  made  within  a  week  after  her  reception  into  the 
hospital,  and  therefore  not  three  weeks  from  the  apparent  beginning 
of  the  complaint,  whitish  nodular  cancerous  spots,  many  of  them  soft, 


DISEASES  OF  THE  LIVER.  59T 

were  found  in  the  substance  of  the  liver,  but  not  at  its  edges,  nor' 
forming  anywhere  distinct  protuberances. 

The  similarity  of  certain  cases  of  protracted  catarrhal  jaundice  in 
elderly  persons,  presenting  emaciation,  with  nausea,  retching,  and  vom- 
iting, has  been  above  mentioned.  The  physical  signs  of  the  enlarge- 
ment of  the  liver  may  or  may  not  assist  us,  according  to  their  charac- 
ter, but  uniform  enlargement  without  nodules  and  absence  of  marked 
tenderness  would  be  in  favor  of  the  non-malignant  view.  The  same 
points  help  us  where  inflammatory  thickening  about  the  biliary  pas- 
sages has  happened  in  consequence  of  gall-stones. 

Syphilitie  Liver. — As  a  consequence  of  constitutional  syphilis,  the- 
liver  may  at  times  exhibit  cicatrices  on  its  surface,  and  scattered 
nodules,  consisting  of  connective  tissue,  and  extending  into  the  paren- 
chyma. This  condition  is  styled  syphilitic  inflammation  of  the  liver,, 
or  the  syphilitic  liver.  The  organ  becomes  uneven  from  the  contrac- 
tion of  the  cicatrized  parts,  and  is  apt  to  be  somewhat  increased  in 
size,  from  coexisting  amyloid  degeneration  or  interstitial  hepatitis.- 
The  patient  has  a  pale,  cachectic  look,  but  is  not  jaundiced,^  except 
from  a  temporary  catarrh  of  the  bile-ducts ;  nor  is  dropsy  present,, 
unless  there  be  at  the  same  time  an  affection  of  the  kidneys  or  enlarge- 
ment of  the  spleen.  But  the  most  important  elements  in  the  diag- 
nosis are  the  age  of  the  patient,  the  history  of  the  case,  and  the 
detection  of  syphilitic  cicatrices  in  the  throat.  When  contrasted  with 
cancer,  we  find,  besides  these  points,  the  chief  distinctive  marks  to 
be :  the  much  more  usual  absence  of  jaundice,  of  dropsy,  and  of 
pain,  the  increase  in  size  of  the  spleen,  the  want  of  local  tenderness, — 
unless  this  be  due  to  passing  attacks  of  perihepatitis, — the  slow 
growth  of  the  liver,  and  the  smaller  size  and  softer  feel  of  the  nodules. 
There  are  cases  of  syphilis  of  the  liver  in  which  an  interstitial  hepa- 
titis is  chiefly  present,  and  which  are  scarcely  to  be  distinguished 
from  cirrhosis,  except  by  the  history  and  general  evidences  of  syphilis.. 
Syphilis  of  the  liver  may  be  hereditary. 

Affections  of  the  Gall-Bladde7\ — Dilatation  and  cancer  of  the  gall- 
bladder are  both  very  liable  to  be  mistaken  for  cancer  of  the  liver. 
The  former  affection  may  result  from  occlusion  of  the  hepatic  and 
common  bile-ducts,  or  it  may  be  owing  to  the  distention  of  the- 
bladder  with  an  albuminous  fluid, — the  so-called  dropsy  of  the  gall- 

^  No  jaundice  is  mentioned  in  the  cases  of  Dittrich,  Prag.  Vierteljahrschr.,  Bd. 
vi.  and  vii.  ;  of  Gubler,  Memoires  de  la  Societe  de  Biologie,  tome  iv.  ;  of  Bam- 
berger, Krankheiten  der  Leber,  in  Virchow,  Pathologie,  etc.  ;  or  of  Moxon,  in  Guy's 
Hospital  Reports,  1867.  In  the  cases  of  Murchison,  Diseases  of  the  Liver,  2d 
edit.,  1877,  it  was  a  passing  or  an  absent  symptom. 


598  MEDICAL   DIAGNOSIS. 

bladder.  In  either  instance  the  bladder  may  attain  an  enormous 
Tolume,  and  give  rise  to  a  marked  tumor  at  the  lower  margin  of  the 
liver.  The  prominence  is  apt  to  be  rounded  or  pear-shaped,  and, 
except  in  those  instances  in  which  the  occlusion  is  in  the  cystic  duct 
or  at  the  neck  of  the  gall-bladder,  the  impediment  to  the  flow  of  bile 
is  accompanied  by  intense  jaundice  and  by  decided  hepatic  swelling. 
In  the  uniform  enlargement  of  the  liver,  the  peculiar  contour  of  the 
prominence,  the  absence  of  ascites,  the  paroxysms  of  pain  preceding, 
not  following,  as  in  cancer  of  the  liver,  the  other  marked  symptoms, 
and  the  history  of  the  case,  which  not  infrequently  points  to  repeated 
attacks  of  colic  from  the  passage  of  gall-stones,  we -find  the  clue 
which  permits  us  to  determine  that  we  are  not  dealing  with  hepatic 
cancer.  In  reaching  a  conclusion  we  must,  however,  bear  in  mind 
that  distention  of  the  •  gall-bladder  from  secondarily  enlarged  can- 
cerous glands  pressing  on  the  common  duct  often  occurs. 

Cancer  of  the  gall-bladder  is  scarcely  ever  met  with  in  young 
persons,  and  is,  as  a  rule,  associated  with  cancerous  formations  in  the 
liver  or  in  other  organs.  It  is  difficult  to  make  out  a  certain  diagnosis 
of  the  affection,  for  it  presents  a  strong  likeness  both  to  cancer  of  the 
pyloric  extremity  of  the  stomach  and  to  cancer  of  the  liver.  From 
the  latter  it  is  undistinguishable,  unless  the  situation  and  form  of  the 
tumor  be  such  that  we  can  clearly  recognize  it  as  belonging  to  the 
gall-bladder.  Sometimes  it  is  preceded  by  a  history  of  gall-stones.^ 
Jaundice,  as  in  cancer  of  the  liver,  may  be  absent  or  present :  in  five 
cases  reported  by  Bamberger^  it  was  found  in  all,  and  was  even  in- 
tense. Frerichs,  on  the  other  hand,  states  that  in  most  instances  it  is 
wanting.  Musser^  finds  it  reported  in  sixty-nine  out  of  a  hundred 
cases.  In  sixty-eight  out  of  one  hundred  cases  analyzed  by  him  a 
tumor  was  discovered,  the  position  of  which  is  most  frequently  in  the 
right  hypochondrium  and  the  umbilical  region,  and  which  is  painful 
on  pressure.  There  is  also  gradually  increasing  pain  and  a  sense  of 
weight  in  the  right  hypochondrium.  The  disease  is  more  common 
in  women  than  in  men.  The  signs  of  the  cancerous  cachexia  are 
strongly  marked ;  as  a  rule,  more  strongly  than  in  hepatic  cancer. 
In  tumors  affecting  primarily  the  ducts,  there  is  early  and  intense 
jaundice.* 

Gall-stones  occasionally  accumulate  in  the  gall-bladder  in  such 
numbers  as  to  give  rise  to  a  hard,  even   nodulated  swelling,  which 

^  Murchison,  op.  cit. 

^  Krankheiten  des  Digestions-Apparates. 

^  Transact.  Assoc.  Amer.  Phys.,  vol.  iv. ,  1889. 

*  Rolleston,  Med.  Chronicle,  Jan.  1896;  Kelynaek,  ibid.,  Nov.  1897. 


DISEASES  OF  THE   LIVER.  599 

may  be  mistaken  for  cancer.  But  the  tumor  is  generally  movable,  is 
not  painful  on  pressure,  and  does  not  alter  in  size,  or  does  so  but 
slowly.  Sometimes  the  patient  complains  of  the  feeling  of  a  weight 
rolling  from  side  to  side  when  he  turns  in  bed,  and  on  palpation  a 
crackling  sound  is  produced,  which  is  readily  discerned  with  the 
stethoscope.  Generally  we  obtain  a  history  of  bilious  colic.  There 
may  or  may  not  be  jaundice ;  there  is  an  absence  of  the  cachectic 
symptoms  of  cancer.  But  we  must  always  remember  that  gall-stones 
are  frequently  combined  with  cancer  of  the  liver  or  gall-bladder. 

Cancer  of  the  Stomach. — This  is  discriminated  from  cancer  of 
the  liver  by  the  far  more  constant  vomiting,  by  the  more  obvious 
symptoms  of  indigestion,  and  by  the  persistent  pain  in  the  stomach. 
Moreover,  the  seat  of  the  tumor  is  different ;  it  is  epigastric,  or  ex- 
tending downward,  but  not  often  passing  into  the  right  hypochon- 
drium,  and  it  shows  on  percussion  a  very  different  contour  from  an 
enlarged  liver.  Yet  there  are  cases  in  which  we  are  kept  in  doubt ; 
especially  those  in  which  the  left  lobe  of  the  liver  chiefly  is  affected 
with  cancer  and  presses  upon  the  stomach,  inducing  perhaps — and 
thus  makmg  the  likeness  still  closer — obstinate  vomiting.  The  only 
traits  of  distinction  are  then  found  in  the  presence  or  absence  of 
marked  derangement  of  the  functions  of  the  liver,  and  m  the  chemical 
examination  of  a  trial  meal. 

Cancer  of  the  Omentum. — The  absence  of  jaundice,  and  the  unal- 
tered appearance  of  the  stools,  are  here,  too,  of  great  value  in  indi- 
cating that  a  tumor  near  or  joining  the  left  lobe  of  the  liver  is  not  due 
to  cancer  of  that  viscus.  Moreover,  the  boundaries  of  the  morbid 
mass  are  different  from  those  of  a  diseased  liver.  But  we  cannot 
always  trust  to  this.  Cancerous  tumors  of  the  lesser  omentum  may 
so  surround  the  liver,  and  correspond  so  closely  to  the  regular  form 
produced  by  hepatic  cancer,  that  the  two  maladies  cannot  be  distin- 
guished ;  at  least  not  by  the  local  signs.  Again,  a  loop  of  intestine 
may  be  thrust  across  the  enlarged  liver  at  a  point  corresponding  to 
the  usual  limit  of  the  percussion  dulness  of  its  left  lobe,  thus  dividing 
the  most  prominent  nodules  from  the  greater  portion  of  the  viscus, 
and  making  it  appear  as  if  the  tumor  were  to  the  left  of,  and  below, 
the  stomach,  and  belonged,  therefore,  probably  to  the  omentum.^  In 
such  cases  we  have  to  depend  entirely  upon  the  signs  of  disturbed 
liver  function. 

Enlargement  of  the  Right  Kidney. — A  tumor  formed  by  an  enlarge- 
ment of  the  kidney  does  not  present  the  same  outline  of  percussion 

^  See  case,  Proceedings  Pathological  Society  of  Phila.,  vol.  i.  p.  275. 


600  MEDICAL  DIAGNOSIS. 

dulness  as  a  cancerous  liver.  The  dulness  is,  moreover,  surrounded 
by  the  tympanitic  sound  of  the  intestine,  and  is  not  lowered  by  a  deep 
inspiration ;  and  ttie  signs  of  disturbed  function  of  the  kidney,  and  an 
examination  of  the  urine,  will  generally  materially  assist  the  diag- 
nosis. Still,  cases  may  occasionally  happen  in  which,  owing  to  a 
peculiar  shape  of  the  diseased  kidney  and  to  the  obscurity  of  the- 
symptoms,  an  error  in  diagnosis  can  scarcely  be  avoided.^ 

Finally,  in  reviewing  the  diagnosis  of  cancer  of  the  liver,  we  must 
inquire  whether  other  than  cancerous  growths,  such  as  sarcoma,, 
melano-sarcoma,  myxoma,  epithelioma,  cysto-sarcoma,  angioma, 
lymphadenoma,  can  be  distinguished  from  true  cancer.  They  may 
produce  identical  physical  signs  and  symptoms ;  indeed,  a  distinction 
is  impossible,  unless  the  history  of  the  case  and  finding  tumors  else- 
where enable  us  to  make  it.  Much  the  same  may  be  said  of  that  rai*e- 
disease,  tubercular  formations  in  the  liver.  Leukasmic  livers  may 
attain  enormous  size,  and  be  mistaken  for  cancer ;  and  the  cachexia 
that  attends  them  makes  the  error  more  likely.  But  the  swelling  of 
the  spleen  and  of  the  lymphatic  glands  and  the  microscopical  exami- 
nation of  the  blood  furnish  the  points  in  diagnosis. 

Hydatids  of  the  Liver. — The  development  of  one  or  of  several 
cysts  in  the  liver,  containing  within  them  echinococci,  is  not,  as  a. 
rule,  a  disorder  which  occasions  serious  disturbance  of  the  general 
health.  Nor  do  the  hydatids  usually  give  rise  to  either  jaundice, 
dropsy,  or  any  marked  signs  of  gastric  or  of  intestinal  irritation,  or  to 
fever,  or  to  local  pain.  Their  most  constant  manifestations  are  a 
decided  increase  of  the  size  of  the  liver,  and  the  presence  of  elastic 
tumors  chscernible  in  the  hepatic  region.  In  some  instances  xanthe- 
lasma has  been  noticed.  This  disorder  of  the  skin,  however,  is  not 
peculiar  to  hydatids,  but  has  been  observed  in  connection  with  other 
forms  of  hepatic  enlargement  associated  with  chronic  jaundice.  There 
is  excretion  of  large  quantities  of  urea.^ 

The  growth  of  the  hydatid  is  generally  very  slow,  and  usually  in 
one  direction  only, — upward,  downward,  laterally.  Very  commonly 
the  hydatid  tumor  grows  from  the  right  lobe.  In  most  cases  it  attains, 
considerable  dimensions,  and  the  liver  may  be  found  to  encroach 
upon  the  lung  as  far  as  the  second  intercostal  space,  or  to  extend 
far  down  into  the  abdominal  cavity.     On  percussion,  the  line  of  dul- 

1  Vidal  (Bulletin  de  la  Soci6t6  Medicale  des  Hopitaux,  1874)  cites  errors  in 
diagnosis  between  tumors  of  the  kidneys,  especially  hydronephrosis,  and  diseases 
of  the  liver  attended  with  enlargement,  like  abscess  or  cancer,  made  by  such 
masters  in  our  art  as  Velpeau,  Nelaton,  Gosselin. 

2  Posselt,  Deutsches  Archiv  fiir  klinische  Medicin,  Bd.  Ixiii.,  1899: 


DISEASES  OF  THE  LIVER.  601 

iiess  either  of  the  upper  or  of  the  lower  boundary  of  the  viscus,  or 
of  both,  is  perceived  to  be  very  irregular,  and  occasionally  on  striking 
a  series  of  abrupt  blows  we  discern  a  peculiar  vibration,  similar  to 
the  sensation  perceived  on  striking  a  mass  of  jelly,  and  very  signifi- 
cant of  the  existence  of  the  cyst.  Owing  to  the  pressure  the  in- 
creasing tumor  may  exert  on  adjacent  structures,  Ave  observe  in  some 
cases  dry  cough  ;  palpitation  and  displacement  of  the  heart ;  vomiting  ; 
possibly  slight  jaundice. 

A  fatal  issue  may  at  any  time  ensue  by  the  hydatid  tumor  bursting 
into  the  pleura,  or  the  pericardium,  or  the  peritoneum,  and  leading  to 
violent  inflammation ;  or  by  suppuration  occurring  in  the  sac,  when 
the  symptoms  become  those  of  pyaemia.  Urticaria  has  been  specially 
noticed  in  connection  with  the  rupture  of  the  cysts. 

In  some  countries  hydatids  are  frequent ;  it  is  not  so  in  this  coun- 
try. In  Iceland  these  growths  developed  from  the  eggs  of  a  tape- 
worm are  so  common  that  they  cause  one-seventh  of  the  human  mor- 
tality. In  point  of  diagnosis,  it  is  not  generally  difficult  to  detect  the 
presence  of  hydatids.  The  disease  differs  from  abscess  of  the  livei^  by 
the  want  of  febrile  action,  pain,  and  great  constitutional  disturbance  ; 
indeed,  the  latent  character  of  the  hydatid  tumor  becomes  of  much 
importance.  Its  slow  growth,  too,  is  very  significant.  When,  as 
sometimes  happens,  a  hydatid  tumor  inflames  and  suppurates,  we 
have  nothing  to  guide  us  in  the  differential  diagnosis  but  the  history 
previous  to  the  development  of  the  urgent  symptoms.  From  cancer 
of  the  liver  we  distinguish  hydatids  by  the  long  duration  of  the  case, 
by  the  absence  of  evident  cachexia,  of  local  tenderness,  and  of  un- 
evenness  of  the  surface.  On  the  other  hand,  we  have  in  hydatid 
tumor  the  sensation  on  palpation  of  elasticity  or  fluctuation.  Under 
rare  circumstances  this  may  happen  in  medullary  cancer,  but  the 
rapid  growth  of  the  latter  and  the  cachectic  symptoms  would  deter- 
mine the  diagnosis.  A  distended  gall-bladder  may,  like  hydatid  tumor, 
be  free  from  pain  on  pressure,  but,  unlike  this,  it  is  movable,  is  pre- 
ceded by  attacks  of  colic,  is  generally  accompanied  by  deep  jaundice, 
and  its  situation  corresponds  to  that  of  the  normal  gall-bladder. 

An  aneurism  of  the  aorta  differs  from  hydatids  in  the  severe  pain 
the  patient  suffers,  so  utterly  dissimilar  to  the  absence  of  pain  or  to 
the  mere  feeling  of  tension  and  weight  of  a  hydatid  swelling.  Then 
the  pulsation  and  the  other  physical  signs  aid  us.  In  aneurism,  of  the 
hepatic  artery^  which  may  also  present  a  smooth,  throbbing  tumor,  we 
are  apt  to  have  deep  jaundice  from  compression  of  the  biliary  ducts. 

Pleuritic  effusions  have  many  features  in  common  with  those  cases 
of  hydatids  of  the  liver  in  which  the  growing  tumor  extends  upward 


602  MEDICAL  DIAGNOSIS. 

into  the  chest.  All  the  physical  signs  of  a  large  effusion  may  be 
present,  even  the  dilatation  of  the  thorax  and  a  sense  of  fluctuation 
in  the  intercostal  spaces.  But  the  absence  of  constitutional  symp- 
toms, the  irregular  outline  of  the  dulness  on  percussion  of  the  hy- 
datid cyst,  the  great  displacement  of  the  heart,  and  the  decided  lowering- 
of  the  upper  margin  of  dulness  upon  deep  inspiration,  enable  us  com- 
monly to  detect  the  real  nature  of  the  disease.  When  the  cyst  has 
opened  into  the  lung  and  the  hydatids  are  being  expectorated  through 
the  air-passages,  the  harassing  cough,  the  copious  sputum,  and  the 
inflammation  of  the  pulmonary  tissue  which  is  apt  to  be  occasioned, 
may  cause  the  affection  to  be  mistaken  for  pulmonary  abscess  or 
phthisis.  The  surest  marks  of  distinction  are  furnished  by  the 
changed  form  of  the  lower  part  of  the  thorax,  and  by  finding  bile  and 
the  hooks  of  the  echinococci  in  the  sputum. 

Renal  enlargements,  such  as  cysts,  hydronephrosis,  cancer,  are  dis- 
criminated from  hydatids  of  the  liver  by  the  same  physical  signs  that 
distinguish  them  from"  hepatic  cancer, — chiefly  by  the  renal  tumor 
having  the  tympanitic  sound  of  the  colon  in  front  of  it,  by  its  being 
but  slightly,  if  at  all,  afiected  in  position  by  deep  mspiration,  and  by 
the  direction  of  its  growth.  Moreover,  the  history  and  an  examina- 
tion of  the  urine  will  greatly  assist. 

Ovarian  cysts,  unlike  hydatids,  grow  from  below  upward,  are  not 
influenced  by  deep  inspiration,  and  produce  enlargements  greatest 
below  and  not  above  the  umbilicus  ;  then  they  have  a  different  out- 
line on  percussion  from  hydatid  liver. 

But,  though  we  may  thus  generally  distinguish  hydatids  of  the  liver 
from  the  maladies  which  have  similar  symptoms,  there  are  unques- 
tionably cases  in  which  it  is  extremely  difficult  to  arrive  at  a  satisfac- 
tory conclusion.  Under  these  circumstances,  an  exploratory  exami- 
nation with  an  aspirator  would  be  proper.  We  may  detect  shreds  of 
striated  hydatid  membrane,  and  portions  of  echinococci.  Besides, 
the  character  of  the  fluid  will  assist  us  in  diagnosis.  It  is  as  clear 
and  colorless  as  water,  has  a  neutral  reaction,  a  specific  gravity  of 
1005  to  1011,  and  contains  not  a  trace  of  albumin  or  of  urea,  but 
large  cpantities  of  chloride  of  sodium.  No  other  fluid  in  the  human 
body,  whether  in  health  or  in  disease,  presents  these  peculiarities. 

Occasionally  portions  of  the  liver  are  transformed  into  a  mass 
consisting  of  connective-tissue  stroma  and  numerous  cells  filled  with 
a  gelatinous  substance.  The  disorder  looks  like  alveolar  carcinoma, 
but  it  is  really  multilocular  hydatids,  or  echinococcus  tumors.  The 
centre  of  the  mass  suppurates,  but  even  this  does  not  diminish  the 
resistance  of  the  hepatic  tumor ;  nor  is  fluctuation,  save  in  the  rarest 


DISEASES  OF  THE  LIVER.  603 

instances,  perceptible.  Elevations  may  be  found,  such  as  we  observe 
in  carcinoma  and  syphiloma  :  indeed,  the  affection  is  not  to  be  distin- 
guished with  any  certainty  from  either,  except  it  be  by  the  history  and 
the  attending  constitutional  symptoms.  No  jaundice  usually  accom- 
panies the  hard  hepatic  swelling ;  but  in  cases  in  which  the  bile-ducts 
are  obstructed  we  meet  with  jaundice  without  dyspeptic  symptoms 
or  previous  paroxysms  of  pain,  and  usually  without  enlargement  of 
the  gall-bladder.  In  cases  with  icterus,  unlike  what  we  find  in  syphilis 
or  in  cancer,  there  is  complete  decoloration  of  the  faeces.^ 

Let  us  now,  in  concluding  the  review  of  the  hepatic  maladies 
which  are  attended  with  decided  increase  of  the  size  of  the  organ, 
briefly  contrast  their  most  important  manifestations.  We  have  found 
that,  as  regards  the  enlargement,  they  differ  materially.  Simple  con- 
gestion, chronic  inflammation,  fatty  liver,  hypertrophic  cirrhosis,  do 
not  attain  nearly  the  volume  of  cancer,  of  hydatids,  of  abscess,  of 
waxy  disease  of  the  liver.  The  three  affections  first  mentioned 
differ,  moreover,  from  all  the  others,  except  the  waxy  liver,  by  pre- 
senting a  uniform  and  not  an  irregularly  shaped  swelling  or  an  uneven 
outline  of  the  percussion  dulness. 

Concerning  the  symptoms,  we  observe  that,  although  these  hepatic 
disorders  all  agree  in  not  being  characterized  by  jaundice,  yet  this 
sign  is  more  commonly  present  and  more  distinct  in  some  than  in 
others.  In  hydatids,  and  in  the  syphilitic  liver,  there  is  no  yellow^ 
hue  of  the  skin  or  of  the  conjunctiva ;  so,  too,  as  a  rule,  in  waxy 
liver.  In  fatty  liver  and  in  abscess  it  is,  on  the  whole,  most  fre- 
quently wanting.  The  same  may  perhaps  be  said  of  cancer,  yet  not 
infrequently  there  is  deep  jaundice  in  this  malady.  In  chronic 
congestion,  in  chronic  inflammation,  and  in  hypertrophic  cirrhosis,, 
we  ordinarily  find  jaundice,  though  it  may  be  but  a  slight  yellow 
tinge  of  the  skin  and  the  eye.  With  reference  to  dropsy,  we  are  not 
apt  to  encounter  it  in  any  of  the  hepatic  affections  under  considera- 
tion except  cancer,  and  waxy  disease  when  more  than  the  liver  is 
implicated.  It  is  in  these  two  complaints,  also,  that  the  most  obvi- 
ous signs  of  a  cachexia  are  met  with  ;  while  in  abscess  we  find  fever,, 
and,  perhaps,  the  greatest  constitutional  disturbance. 

As  regards  j^^ain,  the  fatty  liver,  hydatids,  simple  hypertrophy,  and 
the  waxy  hver  are  painless  ;  the  most  painful  are  cancer,  acute  chole- 
cystitis, and  abscess.  Pain  is  a  less  prominent  symptom  in  syphilis 
of  the  liver  and  hypertrophic  cirrhosis. 

^  See  the  cases  of  Friedreich  and  of  Niemeyer,  referred  to  in  Niemeyer's 
Practice  of  Medicine. 


^04  MEDICAL   DIAGNOSIS. 

Chronic  Diseases  attended  with  Decreased  Size  of  the 
Liver,  and  with  Abdominal  Dropsy. 

Cirrhosis. — Increase  of  connective  tissue  producing  hardening 
■of  the  organ  is  the  underlying  change  in  all  forms  of  cirrhosis  of  the 
liver.  The  atrophic  form  with  its  granulations  of  various  size,  the 
"  hobnail  liver,"  is  the  most  common  form,  and  alcohol  the  common 
€ause.  But  this  cause  does  not  explain  all  cases :  in  some,  the 
malady  is  connected  with  syphilis  ;  in  others,  ^vith  malaria ;  in  others, 
vidth  anthracosis  ;  in  others,  with  infective  diseases  ;  m  others,  again, 
it  cannot  be  attributed  to  any  known  agency,  and  has  been  stated  to 
be  due  to  microbic  infection.  Again,  there  may  be  granular  livers 
in  which  the  fibroid  tissue  is  formed  between  the  lobules,  and  which 
never  contract, — an  interstitial  hepatitis,  or  hypertrophic  cirrhosis. 
Cirrhosis  is  essentially  a  disease  of  middle-aged  men ;  it  is  far  less 
common  in  women,  and  rare  in  children.^ 

In  the  first  stage  of  cirrhosis,  the  ordinary  or  alcoholic  cirrhosis, 
as  it  is  sometimes  termed,  the  organ  is  somewhat  increased  in  size ; 
then  the  bulk  becomes  lessened.  It  is,  however,  doubtful  whether 
the  stage  of  enlargement  invariably  precedes  that  of  shrinking :  the 
process  of  reduction  constitutes  not  infrequently  the  first  change. 
But,  without  entering  into  this  question,  we  may  state  that  there  are 
no  symptoms  by  which  we  can  recognize  the  disease  at  an  early 
period,  for  the  symptoms  at  first  are  the  same  as  those  of  chronic 
congestion, — dull  pain,  perhaps  tenderness  at  the  hypochondrium 
and  pain  referred  to  the  shoulder,  disordered  digestion,  and  a  sallow 
or  a  slightly  jaundiced  hue  of  the  skin.  Nor  can  we  say,  even  after 
the  stage  of  contraction  is  fairly  developed, — and  it  may  never  reach 
the  point  of  the  hobnail  liver  being  really  small, — that  the  diagnosis 
of  the  affection  is  always  possible.  It  may  rest  on  no  stronger  grounds 
than  finding  in  a  person  who  is  known  to  be  a  spirit-drinker,  "a 
tippler,"  an  intractable  ascites,  without  obvious  ..cause  for  the  dropsy. 
The  dropsy,  due  to  the  obstruction  of  the  portal  circulation,  consists 
throughout  strikingly  of  ascites ;  as  it  increases,  cedema  of  the  legs 
may  be  developed,  and  passing  albuminuria,  from  pressure  on  the 
renal  veins,  or  beginning  cirrhosis  of  the  kidney. 

Besides  the  dropsy,  the  other  clinical  features  of  the  malady  are 
not  very  marked.  The  most  significant  signs  consist  in  the  diminu- 
tion of  the  percussion  dulness  in  the  hepatic  region,  and  the  detection, 
by  the  touch,  of  firm,  irregular  granulations  on  the  margin  and  under 

^  See,  however,  cases  by  Howard,  Transact.  Assoc.  Amer.  Phys.,  1887. 


DISEASES  OF  THE  LIVER.  605 

surface  of  the  liver.  But  both  these  signs  are  very  difficult  to  discern, 
on  account  of  the  distention  of  the  abdomen  with  fluid,  and  the  dis- 
placement of  the  liver  this  may  occasion.  In  fact,  it  is  often  only 
after  the  performance  of  paracentesis  that  the  abdominal  walls  will 
permit  us  to  judge  with  any  accuracy  of  the  shrinking  and  altered 
state  of  the  organ.  This  is  especially  true  with  reference  to  palpa- 
tion ;  as  regards  percussion,  it  may  be  possible,  even  when  the  abdo- 
men is  still  full  of  dropsical  effusion,  to  detect  the  lessened  extent  of 
hepatic  dulness. 

Irrespective  of  these  phenomena,  we  find  at  times  other  mani- 
festations of  disease  which  assist  us  in  the  diagnosis  of  cirrhosis. 
They  are  enlargement  of  the  spleen ;  dilatation  of  the  veins  of  the 
abdomen  ;  gastric  and  intestinal  derangements  ;  hemorrhoids  ;  marked 
loss  of  flesh  and  strength ;  jaundice  coming  and  going,  never  very 
striking ;  a  decidedly  cachectic  appearance,  with  sunken  features ; 
and  hemorrhages  from  the  nose  and  mouth,  or  from  the  stomach  or 
intestines,  or  into  internal  cavities.  Hsematemesis  in  an  alcoholic 
must  ahvays  arouse  suspicion.  The  increase  in  size  of  the  spleen  is 
far  from  constant,  and  rarely  reaches  a  considerable  extent.  There  is 
often  pain  over  the  region  of  the  liver  and  spleen,  and  occasional  at- 
tacks of  perihepatitis  and  of  peritonitis  occur.  The  dilatation  of  the 
abdominal  veins  is  not  perceived  until  an  advanced  stage  of  the  dis- 
ease, and  is  sometimes  connected  with  a  peculiar  vascular  net-work, 
stretching  from  the  umbilicus  upward  and  downward,  and,  as  Sappey ' 
was  the  first  to  describe,  with  a  decided  enlargement  of  the  epigastric 
and  mammary  veins,  the  blood  flowing  through  the  former  in  a  re- 
versed direction  from  what  it  does  in  health, — namely,  not  towards 
the  liver,  but  from  it  to  the  veins  of  the  abdominal  wall,  and  thence  to 
the  vena  cava.  Other  external  veins  share  in  the  enlargement ;  the 
veins  of  the  legs  may  be  varicose,  and  the  venous  twigs  on  the  cheeks 
become  developed.  In  some  cases  an  irregular  but  .moderate  fever 
not  exceeding  102.5°  is  also  noticed  ;  very  generally  there  is  none. 

Another  symptom  to  which  I  have  had  my  attention  strongly 
directed  is  the  presence  of  small  amounts  of  sugar  in  the  urine. 
Thus,  in  two  cases  which  I  saw  with  Dr.  Simpson,  Trommer's  test 
readily  detected  sugar  in  the  urine.  In  the  one  case  the  secretion 
was  scanty  ;  in  the  other  it  was  abundant.  One  had  lasted  for  several 
years,  and  was  slowly  developing ;  the  other  had  existed  about  sixteen 
months,  and  was  rapidly  progressing. 

Cerebral  symptoms  due  to  a  toxic  cause  sometimes  appear.     They 

^  Bulletin  de  I'Acad^rnie  de  M6decine,  tome  xxiv. 

38 


606  MEDICAL  DIAGNOSIS. 

show  themselves  frequently  in  a  delirium  of  mild  type,  attended  with 
confusion  of  persons  and  places.  The  delirium  is  often  like  that  of 
uraemia,  but  there  is  nothing  in  the  urine  to  account  for  it.  It  may 
not  show  itself  until  towards  the  end  of  the  disease  ;  on  the  other 
hand,  it  may  be  of  long  duration.  In  a  case  I  saw  with  Dr.  Lloyd,  it 
lasted  four  months.     Coma  and  convulsions  also  occur  occasionally. 

The  gastric  and  intestinal  derangements,  the  result  of  a  congested 
or  inflamed  mucous  membrane,  are  rarely  wanting :  they  manifest 
themselves  by  failing  appetite,  impaired  digestion,  both  gastric  and 
intestinal,  morning  sickness,  flatulency  and  constipation,  or  the  fre- 
quent voiding  of  pale-colored  stools  or  attacks  of  diarrhoea.  The 
jaundice  very  rarely  attains  a  high  degree.  It  shows  itself  usually  in 
a  yellowish  tinge  of  the  skin  and  conjunctiva ;  but  even  this  hue  is 
often  absent,  and  we  find  the  pale  skin  and  pearly  eye  of  anaemia. 

Yet  not  one  of  these  symptoms  is  really  characteristic ;  they 
become  so  only  when  viewed  in  connection  with  the  dropsy,  with  the 
local  signs  m  the  hepatic  region,  with  the  history  of  the  case,  and 
with  the  absence  of  any  organic  disease  of  the  stomach  or  the  intes- 
tine, which  might  explain  them.  Then  the  age  of  the  patient,  gener- 
ally above  thirty-five  years,  and  his  habits,  must  be  taken  into  account. 
The  cirrhosis  of  young  children  is  generally  due  to  inherited  syphilis. 
Gout  seems  to  predispose  to  the  disease.  Murchison  tells  us  that  the 
condition  of  the  liver  which  develops  gout  renders  it  liable  to  suffer 
from  alcohol.  Cirrhosis  of  the  liver  often  becomes  associated  with 
acute  tuberculosis.     At  times  cirrhosis  runs  a  rapid  course.^ 

There  is  a  form  of  cirrhosis  due  to  infection.  It  has  been  de- 
scribed as  subacute  infectious  hepatitis.^  It  is  attended  with  irregular 
fever  of  remittent  or  intermittent  type,  with  decided  enlargement  of 
the  spleen  and  splenic  pain,  with  urobilin  in  the  urine,  with  greatly 
lessened  renal  excretion  of  urea,  but  ureic  sweating,  with  slight  jaun- 
dice and  cirrhotic  diminution  of  the  size  of  the  liver.  The  infection 
occurs,  probably,  through  the  intestine,  and  from  the  liver  spreads 
along  the  hepatic  veins  to  the  vena  cava,  and  may  ultimately  infect 
the  arterial  system,  giving  rise  to  infectious  nephritis  and  purulent 
meningitis.  A  similar  disease  is  met  with  in  children,  a  cirrhosis  with 
jaundice  after  infectious  maladies,  such  as  scarlet  fever  or  measles. 

Another  form  of  cirrhosis,  if  it  be  a  form  and  not  a  separate  dis- 
ease, by  comparison  rare,  has  been  mentioned, — hypertrophic  cirrhosis, 

1  Hanoi,  "  Cirrhose  atrophique  a  marche  rapide,"  Arch.  Gen.  de  Med.,  June, 
1882. 

-  Levi,  Arch.  Gen.  de  Med.,  April,  1894. 


DISEASES  OF  THE  LIVER.  607 

or  "  interstitial  hepatitis,"  or  cirrhotic  enlargement.  It  may  be  found 
in  alcoholics,  but  often  shows  itself  without  recognizable  cause.  It  is 
frequently  noticed  in  young  persons.  It  has  much  the  same  symp- 
toms as  atrophic  cirrhosis,  and  is  undistinguishable,  except  by  the 
increased  percussion  dulness  it  presents,  and  by  the  signs  of  enlarged 
liver  being  usually  attended  with  more  decided  and  much  more  con- 
stant jaundice  and  greater  tendency  to  protracted  fever  and  to  peri- 
tonitis. Pain  over  the  liver  and  spleen,  due  perhaps  to  attacks  of 
perihepatitis,  is  not  uncommon.  Ascites  is  absent  or  slight.  The 
edge  of  the  enlarged  liver  is  hard  and  not  irregular ;  the  gall-bladder 
is  not  distended.  A  peculiar  mawkish  odor  of  the  breath  has  been 
spoken  of  as  present.^  Dilatation  of  the  abdominal  veins  is  generally 
absent. 

The  disease  usually  begins  with  the  signs  of  congestion,  acute  or 
chronic,  with  jaundice,  and  with  some  pain  in  the  right  hypochon- 
drium,  and  lasts  for  years,  terminating  in  a  slow  cachexia ;  at  the  end 
there  are  marked  jaundice  and  diarrhoea,  and  the  patient  sinks  into  a 
typhoid  state.  Ascites  may  be,  as  already  indicated,  wanting  through- 
out ;  or,  as  is  more  usual,  it  comes  on  late  in  the  malady.  The  disease 
is,  in  my  experience,  not  infrequently  complicated  with  a  fatty  liver, 
forming  "  a  fibro-fatty  liver."  In  some  instances  of  hypertrophic 
cirrhosis  there  is  organic  disease  of  the  heart.  The  infectious  nature 
of  hypertrophic  cirrhosis  has  been  often  affirmed. 

Cirrhosis  of  the  liver  due  to  malarial  infection  is  also  associated 
with  enlargement,  at  times  very  great.  It  presents,  moreover,  a  per- 
sistent chronic  jaundice,  which  may  last  for  years,  and  is  combined 
with  marked  enlargement  of  the  spleen  and  manifestations  of  the 
malarial  poisoning.  Bleeding  from  the  nose,  gums,  and  intestines  is 
frequent ;  dropsy  and  distention  of  the  abdominal  veins  are  absent.^ 
The  disease  I  believe  to  be  a  very  rare  one. 

Let  us  now  look  at  the  distinction  between  ordinary  cirrhosis  and 
some  of  the  maladies  which  resemble  it ;  and  first  let  us  compare  its 
traits  with  those  of  other  hepatic  affections.  From  diseases  of  the 
liver  attended  with  enlargement,  such  as  waxy  liver,  fatty  liver,  and 
chronic  congestion,  fully  developed  cirrhosis  is  discriminated  by  the 
presence  of  ascites  and  the  other  signs  of  seriously  obstructed  portal 
circulation,  by  the  diminished,  or  certainly  not  augmented,  size  of  the 
organ,  and  by  the  different  history  of  the  disorder.  From  hydatids  of 
the  liver  we  diagnosticate  cirrhosis  by  the  irregularity  of  outline  of 


^  Duckworth,  St.  Bartholomew's  Hospital  Reports,  1874. 
^  Lancereaux,  quoted  in  Sajous's  Annual,  1888,  p.  335. 


608  MEDICAL  DIAGNOSIS. 

the  enlarged  liver  in  the  former  complaint,  by  the  sense  of  fluctuation, 
and  by  the  comparatively  unimpaired  general  nutrition  of  the  body. 
Cancer  of  the  liver  is  unlike  cirrhosis  in  the  distinctness  and  size  of 
the  protuberances,  in  the  obvious  hepatic  enlargement,  in  the  less 
marked  ascites,  and  in  the  normal  size  of  the  spleen.  But  when  a 
cirrhosed  liver  is  associated  with  syphilitic  nodules,  or  when  its 
volume  is  augmented  by  waxy  infiltration,  the  discrimination  from 
cancer  becomes  a  matter  of  extreme  difficulty ;  indeed,  it  may  be 
impossible  to  avoid  erroneous  conclusions.  Hypertrophic  cirrhosis 
may  also  be  very  difficult  to  distinguish  from  cancer,  except  by  the 
history  of  alcoholic  dyspepsia,  and,  though  large  and  nodulated,  the 
liver  is  rarely  so  tender,  and  the  nodules,  if  they  can  be  felt  at  all, 
are  small,  and  ascites  is  not,  as  in  cancer,  a  frequent  symptom. 
Syphilitie  hepatitis  cannot  be  distinguished  from  hypertrophic  cir- 
rhosis, save  by  the  history  of  the  case  and  feeling  the  gummata.  In 
some  instances  there  is  distinct  fever,  which  subsides  under  iodide  of 
potassium.  The  general  health  may  be  but  little  disturbed.  In  the 
interstitial  hepatitis  due  to  inherited  syphilis,  enlargement  of  the  liver 
and  jaundice  occur. 

We  shall  now  consider  and  compare  the  clinical  traits  of  some 
diseases  of  the  liver  producing,  like  ordinary  cirrhosis,  atrophy  of  the 
organ. 

As  the  result  of  repeated  attacks  of  perihepatitis,  we  find  great 
thickenmg  of  the  capsule,  with  fibrous  bands  passing  into  the  interior 
of  the  organ,  and  some  atrophy.  This  condition,  described  as  simple 
induration  of  the  liver,  is  met  with  chiefly  in  connection  with  constitu- 
tional syphilis,  though  it  is  also  seen  following  a  right-sided  pleurisy 
and  diseases  of  parts  contiguous  to  the  liver,  producing  inflammation 
which  spreads  to  it.  The  affection  is  not  to  be  distinguished  from  true 
cirrhosis,  except  by  the  causing  elements,  particularly  by  the  syphilitic 
history,  and  by  the  absence  of  the  habit  of  spirit-drinking ;  the  greater 
and  more  persistent  pain  and  tenderness  in  the  hepatic  region  are  of 
significance  ;  sometimes  there  is  coexisting  heart  disease. 

Red  atrophy  is  a  pathological  state  rather  than  a  recognizable  dis- 
ease. The  diminished  hepatic  dulness  is  not  preceded  by  alcoholic 
dyspepsia  or  valve  disease,  but  is  met  with  in  those  with  a 'history  of 
dysentery  or  of  ulceration  of  the  intestine.  It  may  be  also  due  to 
obstinate  malaria,  and  the'  liver  is  then  at  first  large  and  red. 

An  inflammation  of  the  jwrfal  vein,  with  coagida  forming  in  it,  may 
occasion  the  same  manifestations  of  deranged  abdominal  circulation, 
the  same  or  greater  tumefaction  of  the  spleen  and  decrease  of  the 
liver,  as  cirrhosis.     And  what  complicates  the  diagnosis  very  much 


DISEASES  OF  THE  LIVER.  609 

is,  that  cirrhosis  is  the  chief  disease  that  leads  to  thrombosis  of  the 
portal  vein.  Indeed,  we  cannot,  under  any  circumstances,  positively 
discriminate  this  affection  from  cirrhosis.  Still,  we  are  sometimes 
enabled  to  distinguish  the  venous  disorder  by  laying  stress  on  the 
sudden  development  of  the  symptoms,  especially  of  the  violent  en- 
gorgement of  the  portal  system  ;  and  by  noting  the  rapidity  with  which 
the  ascites  returns  after  paracentesis,  the  rapid  swelling  of  the  spleen, 
the  copious  gastric  or  intestinal  hemorrhage,  the  severe  vomiting  and 
diarrhoea,  the  great  enlargement  of  the  abdominal  veins,  and,  when 
not  too  soon  fatal,  the  marked  emaciation.  Other  causes  than  inflam- 
mation of  the  coats  of  the  vein,  whether  simple  or  infective,  may 
produce  coEigulation.  We  may  have  thrombosis  as  the  result  of  dis- 
ease of  the  liver  structure,  in  cirrhosis,  or  cancer,  or  syphilis ;  or  of 
compression  by  enlarged  cancerous  or  tubercular  glands  ;  or  in  conse- 
quence of  the  perforation  of  the  vein  by  cancer  or  by  gall-stones,  or 
of  sclerotic  change  of  its  coats.  Compression  of  the  portal  vein  and 
of  the  biliary  ducts  in  the  fissures  of  the  liver,  from  inflammation 
of  the  surrounding  areolar  tissues,  may  be  separated  from  cirrhosis 
chiefly  by  the  intense  icterus  and  the  complete  decoloration  of  the 
stools. 

Of  non-hepatic  affections,  cirrhosis  is  most  liable  to  be  confounded 
with  Ghronic  peritonitis ;  a  mistake  rendered  the  more  likely  because 
chronic  congestion  or  even  chronic  inflammation  of  the  peritoneum 
may  exist  as  a  complication  of  cirrhosis.  But,  even  when  no  such 
complication  is  present,  the  diagnosis  may  be  difficult.  It  rests  chiefly 
upon  the  greater  and  more  extended  tenderness  of  the  abdomen  in 
peritonitis,  the  febrile  signs,  the  absence  of  splenic  enlargement  and 
of  dilated  veins,  the  usually  unchanged,  or  certainly  not  jaundiced, 
hue  of  the  skin,  the  association  with  signs  of  disease  in  other  viscera, 
especially  of  the  lungs, — for  chronic  peritonitis  is  generally  tubercular. 

Under  rare  circumstances,  cancer  of  the  stomach  may  simulate 
cirrhosis.  I  had  some  years  since  a  case  under  my  charge  at  the 
Pennsylvania  Hospital,  in  which,  with  very  slight  digestive  symptoms, 
and  without  discernible  epigastric  tumor,  considerable  ascites  and 
effusion  into  the  left  pleural  cavity  existed.  Owing  to  this  effusion, 
the  state  of  the  spleen  could  not  be  accurately  ascertained.  There 
was  some  fulness  of  the  abdominal  veins,  and  the  hepatic  percussion 
dulness  did  not  extend  entirely  to  the  margin  of  the  ribs.  Bile-pig- 
ment was  present  in  the  urine,  the  bowels  were  loose,  and  progressive 
emaciation  ensued.  The  man  had  been  very  intemperate,  and  his  case 
might  certainly  have  been  selected  as  an  illustration  of  cirrhosis ;  yet 
at  the  autopsy  the  liver,  though  small,  rather  hard,  and  deeply  con- 


610  MEDICAL  DIAGNOSIS. 

gested,  was  not  cirrhotic,  and  a  cancer  involving  the  whole  stomach, 
except  the  pylorus,  was  found/ 

Chronic  Atrophy  of  the  Liver. — ^Although  cirrhosis  is  the  most 
frequent  it  is  not  the  sole  cause  of  dwindling  of  the  liver.  We  have 
just  spoken  of  its  diminution  in  consequence  of  obstruction  of  the 
trunk  of  the  portal  vein,  as  well  as  of  other  causes  ;  but  besides  these 
causes  we  find  some,  such  as  a  decrease  of  the  organ  from  long-con- 
tinued closure  of  the  common  duct,  or  its  atrophy  in  old  age,  or  in 
connection  with  grave  disease  of  the  heart  or  lungs  obstructing  the 
circulation  and  causing  persistent  hyperasmia  of  the  liver,  or  as  an 
accompaniment  of  chronic  disease  of  the  intestine.  The  first  of  these 
morbid  states  is  mainly  discriminated  by  the  deep  jaundice,  without 
marked  ascites  and  enlarged  abdominal  veins  ;  the  second,  by  the  ab- 
sence of  any  important  symptoms  referable  to  the  liver  and  associated 
with  the  diminished  hepatic  dulness  ;  the  third,  by  the  history  of  the 
case,  the  physical  signs  of  cardiac  or  pulmonary  difficulty,  and  the 
more  general  dropsy.  The  fourth  form  has  been  mentioned  under 
red  atrophy.  We  may  sometimes  suspect  the  cause  of  the  shrinkage 
of  the  organ  from  the  persistent  and  intractable  diarrhoea  and  dis- 
turbance of  the  stomach.  But  there  is  no  cause  of  simple  atrophy 
of  the  liver  so  common  as  thrombosis  of  the  portal  vein. 

SECTION  IV. 

ABDOMINAL    ENLARGEMENT. 

In  describing  the  causes  of  abdominal  enlargement,  I  shall  view 
them  as  they  occasion  a  general  and  uniform  or  a  more  circum- 
scribed and  partial  swelling. 

General  Abdominal  Enlargement. 
Ascites. — The  collection  of  serous  fluid  in  the  peritoneal  sac,  or 
ascites,  may  form  part  of  a  general  dropsy,  and  be  dependent  upon 
an  organic  disease  of  the  kidneys  or  of  the  thoracic  viscera ;  or  the 
accumulation  of  liquid  may  be  confined  to,  or  occupy  principally,  the 
abdomen.  In  either  case  the  local  signs  are  much  the  same.  They 
are :  enlargement  of  the  belly ;  a  dull  sound  on  percussion,  due  to 
the  presence  of  liquid ;  and  the  sense  of  fluctuation  imparted  to  the 
hand  on  one  side  of  the  abdomen  by  a  wave  of  fluid  put  into  motion 
by  a  tap  on  the  other  side. 

^  For  a  fuller  report  of  this  case,  see  Proceedings  of  the  Pathological  Society, 
Amer.  Journ.  Med.  Sci.,  vol.  lii.,  1866. 


ABDOMINAL   ENLARGEMENT.  611 

As  regards  the  former  of  these  signs,  it  is  uniform  and  progressive, 
and  is  generally  very  evident ;  although,  of  course,  when  the  quantity 
of  liquid  is  small,  enlargement  of  the  abdomen  may  escape  detection. 
The  percussion  dulness  is  most  readily  perceived  at  the  lower  portion 
of  the  abdomen,  where  the  fluid  gravitates.  The  bowels  float  usually 
to  the  upper  part  of  the  liquid,  and  at  this  spot  their  tympanitic 
resonance  may  be  distinctly  discerned.  When  the  patient  is  in  the 
erect  position,  the  intestinal  percussion  note  is  commonly  discover- 
able in  the  epigastric  and  umbilical  regions.  If  he  be  placed  upon 
his  back,  the  tympanitic  sound  is  found  to  extend  lower  than  the 
umbilical  region,  while  dulness  will  be  elicited  in  the  hypogastric 
region  and  the  flanks.  If  he  be  placed  upon  his  side,  the  flank 
which  is  uppermost  becomes  resonant.  This  alteration  of  the  level 
of  the  fluid  with  the  change  of  position  is  thus  a  significant  sign, 
and  always  happens  except  when  the  effusion  is  encysted ;  it  is 
detected  without  difficulty,  save  where  great  flatulent  distention  of 
the  bowels  or  impaction  of  fgeces  accompanies  the  accumulation  of 
liquid. 

Ordinarily,  the  fluctuation  wave  felt  by  the. hand  is  easily  dis- 
cerned. It  is  obscured  by  thickening  of  the  abdominal  walls  from 
oedema,  or  from  the  accumulation  of  fat  in  the  subcutaneous  tissues  ; 
it  is,  moreover,  indistinct  if  adhesions  circumscribe  the  fluid  in  the 
peritoneum.  The  amount  of  albumin  in  the  fluid  rises  with  the 
ascites  and  its  duration.  For  all  practical  applications  the  specific 
gravity  determines  the  proportion  of  albumin,  and  the  urinometer 
may  be  employed  for  the  purpose. 

There  are  no  means  of  distinguishing  the  character  of  the  fluid 
except  by  direct  observation.  Chylous  ascites  has  been  not  infre- 
quently found  associated  with  tubercle,^  or  cancer  of  the  peritoneum. 
It  has  also  been  met  with  in  filariasis  and  in  rupture  of  the  thoracic 
duct.  A  hemorrhagic  fluid  indicates  cancer  or  tubercle  of  the  perito- 
neum, though  it  is  occasionally  seen  in  cirrhosis. 

The  other  symptoms  often  found  in  ascites,  such  as  a  pushing 
upward  of  the  liver,  spleen,  and  stomach,  embarrassed  breathing 
compression  of  the  lungs,  and  digestive  disturbances,  present  nothing 
characteristic.  But  we  insist  on  this :  that  a  diagnosis  of  ascites  is 
only  half  a  diagnosis,  and  that  we  should  in  every  instance  endeavor 
to  ascertain  the  cause  of  the  collection  of  fluid  in  the  peritoneal  sac. 
The  morbid  states  with  which  dropsy  in  the  peritoneum  is  liable  to 
be  confounded  are  chiefly  : 

^  Busey,  Amer.  Journ.  Med.  Sci.,  Dec.  1889. 


612  MEDICAL  DIAGNOSIS. 

Ovarian  Dropsy  ; 

Chronic  Peritonitis  ; 

Distention  of  the  Bladder  ; 

Gravid  Uterus  ; 

Chronic  Tympanites. 

Ovarian  Dropsy. — It  is  not  until  an  ovarian  cyst  rises  above  the 
brim  of  the  pelvis  that  it  occasions  a  swelling  marked  enough  to  be 
mistaken  for  abdominal  dropsy.  Supposing  that  it  has  led  to  consid- 
erable enlargement  of  the  belly,  we  are  yet  able  to  discriminate  be- 
tween the  two  disorders  by  attention  to  the  physical  signs  of  the 
history  of  the  case. 

As  regards  the  former,  we  perceive  these  differences :  the  sound 
on  percussion  over  an  ovarian  cyst  is  dull  in  the  umbilical  and  hypo- 
gastric regions,  while  at  the  sides  the  tympanitic  resonance  of  the  in- 
testines may  be  obtained.  Moreover,  the  dulness  in  ovarian  dropsy 
does  not  change  its  position  in  different  postures ;  and,  like  all  ovarian 
tumors,  the  ovarian  dropsy  causes  a  projection  in  the  centre  of  the 
abdomen,  not  a  flattening  there  and  a  bulging  of  the  flanks,  as  is 
common  in  ascites.  Bacefli^  states  that  in  ascites  there  is  a  deep 
tympanitic  sound  during  percussion  in  the  region  of  the  intestines, 
while  an  ovarian  cyst  presents  dulness  on  the  side  in  which  the  cyst 
has  its  origin,  and  a  tympanitic  sound  on  percussion  on  the  other. 
In  ascites,  vaginal  and  rectal  touch  detect  fluctuation  at  once,  and  the 
uterus  is  normal  in  size  and  in  mobility,  sometimes  it  is  prolapsed ; 
in  ovarian  dropsy,  fluctuation  is  less  distinct,  and  may  not  be  found  at 
all,  and  the  uterus  is  generally  displaced  behind  the  cyst. 

The  fluctuation  from  an  ovarian  cyst  is  unequal  at  different  parts 
of  the  distended  abdomen.  When  the  effused  fluid  is  free  in  the 
peritoneal  cavity,  fluctuation  may  be  perceived  beyond  the  line  of 
dulness  as  the  fluid  is  thrown  in  waves  among  the  intestines  ;  but 
when  it  is  confined  within  a  cyst,  fluctuation  cannot  be  perceived 
beyond  the  cyst  walls :  hence  the  outline  of  the  cyst  as  obtained  by 
percussion,  and  that  of  the  area  within  which  fluctuation  is  perceived, 
must  be  the  same.  It  should  be  remembered,  however,  that  fluctua- 
tion in  an  ovarian  cyst  may  escape  detection  on  account  of  the  great 
thickness  of  the  cyst  walls,  or  of  the  unusual  tenseness  of  the  cyst, 
or  of  the  great  density  of  the  fluid,  or  of  the  small  amount  of  fluid  in 
each  cyst.  In  ovarian  cyst  there  is,  for  the  most  part,  impairment  of 
the  general  health,  and  the  color  of  the  face  is  that  of  cachexia. 

When  there  is  ascites  comphcating  an  ovarian  tumor,  the  diagnosis 

^Wien.  Med.  Wochensch.,  April,  1890. 


ABDOMINAL  ENLARGEMENT.  613 

is  very  difficult.  Finding  the  fluctuation  unecjual,  and  an  irregular 
outline  of  the  ovarian  growth,  may  aid  us  ;  but  a  preliminary  tapping, 
though  now  mostly  condemned  by  gynaecologists,  may  be  necessary  to 
arrive  at  an  opinion.  The  specific  gravity  of  the  fluid  of  ovarian  cysts 
is  1020  to  1025,  thus  considerably  higher  than  of  ascitic  fluid,  which  is 
generally  about  1010.  Entire  reliance  cannot  be  placed  on  the  chem- 
ical character  of  the  fluid,  since  the  rule  that  paralbumin  is  significant 
of  ovarian  fluids  and  fibrin  of  serous  fluids  has  many  exceptions. 
Spencer  Wells  ^  accepts  the  presence  of  the  "  granular  cell,"  as  shown 
by  Drysdale  and  W.  L.  Atlee,^  to  be  characteristic  of  ovarian  fluid. 
This  granular  cell  is  generally  round,  sometimes  oval,  varies  in 
diameter  from  one  five-thousandth  to  one  two-thousandth  of  an  inch, 
is  transparent,  is  much  smaller  and  far  less  opaque  than  the  compound 
granular  cell  of  inflammation,  and  contains  a  number  of  fine  granules 
which  become  more  distinct  on  the  addition  of  acetic  acid,  and  nearly 
transparent  under  ether ;  there  is  no  nucleus.^ 

In  uncomplicated  cases,  the  history  assists  us  greatly  in  reaching  a 
correct  diagnosis.  In  ovarian  dropsy,  we  can,  as  a  rule,  make  out 
that  the  distention  of  the  abdomen  has  begun  at  its  lower  portion  on 
one  side,  and  has  spread  upward.  Again,  we  do  not  find  those  signs 
of  disease  of  the  liver,  heart,  kidneys,  or  spleen  which  are  so  apt 
to  coexist  with  ascites,  or  that  the  swelling  is  reduced  by  the  use  of 
hydragogue  cathartics  and  diuretics,  as  in  the  latter  complamt. 

Attention  to  the  history  and  progress  of  the  complaint  is  especially 
valuable  in  the  class  of  cases  in  which  the  physical  signs  of  ascites  are 
modified  by  the  intestines  not  being  able  to  float  to  the  surface  of  the 
fluid  in  the  peritoneal  cavity,  in  consequence  of  adhesions  to  one 
another,  or  of  a  diseased  omentum,  or  in  which  the  fluid  has  been 
limited  in  sacs  by  inflammatory  adhesions.  On  the  other  hand,  an 
ovarian  cyst  may  contain  air,  either  from  a  communication  with  the 
intestine,  or  after  tapping  and  decomposition  of  the  contained  fluid, 
and  percussion  would  then  give  a  clear  note  in  front  and  a  dull  note 
below ;  succussion,  too,  has  been  noticed.  In  the  diagnosis  between 
encysted  dropsy  of  the  peritoneum  and  an  ovarian  cyst,  if  we  obtain, 
by  tapping,  a  spring-water  fluid,  it  points  to  cyst  of  the  broad  ligament. 

Chronic  Peritonitis. — We  find  chronic  peritonitis  as  the  result  of 
an  acute  attack,  or  in  connection  with  cirrhosis  of  the  liver,  with  dila- 

1  Brit.  Med.  Journ.,  June,  1878. 

^  Ovarian  Tumors. 

^  See  Transactions  of  the  Pathological  Society  of  Philadelphia,  vol.  vii.,  1877  ; 
American  Journal  of  Obstetrics,  vol.  xii.,  1879;  also  Gynsecological  Transactions, 
1883. 


614  MEDICAL   DIAGNOSIS. 

tation  of  the  colon,  with  chronic  dysentery,  or  with  interstitial  nephri- 
tis.    But  usually  the  peritonitis  is  either  tubercular  or  cancerous. 

Tubercular  peritonitis  generally  occurs  in  those  who  have  tubercles 
in  the  lungs  or  enlarged  caseous  glands  ;  and  when  such  patients  com- 
jDlain  of  abdominal  pain  and  uneasiness,  of  soreness  to  the  touch,  of 
nausea  and  vomiting,  of  diarrhoea  alternating  with  constipation,  and 
of  losing  flesh  and  strength ;  when  the  tender  abdomen  is  tense,  re- 
sistant, much  distended,  in  part  with  liquid,  but  especially  with  wind, 
and  exhibits  on  its  exterior  the  tracings  of  the  convolutions  of  the 
intestines  ;  when  in  addition  there  is  oedema  of  the  lower  limbs,  with 
fever,  irregular,  at  times  high,  at  times  almost  ceasing,  and  a  growing 
cachexia, — we  can  hardly  be  wrong  in  presuming  the  signs  of  chronic 
peritoneal  inflammation  to  be  owing  to  the  presence  of  tubercle. 
Even  when  disease  of  the  lungs  is  absent,  or  is  not  well  defined,  • 
we  shall  generally  be  correct,  if  the  abdominal  symptoms  mentioned 
exist,  and  there  are  repeated  attacks  of  acute  or  subacute  peritonitis, 
in  determining  the  peritoneal  affection  to  be  tubercular.  Signs  of 
great  significance  are  the  presence  of  nodules  in  the  rectum  and  in 
the  sacro-uterine  ligaments,  and  of  inflammation  around  the  Fallo- 
j)ian  tube.  In  some  instances  the  disorder  develops  with  rapidity, 
and  has  the  aspect  of  an  acute  complaint.  On  the  other  hand  it 
may  be  latent.  The  tumefaction  of  the  belly  may  be  so  great  as  to 
simulate  an  abdominal  tumor.^  The  disease  is  often  mistaken  for 
ovarian  disease. 

A  cancer  of  the  p>C'ritoneum  gives  rise  to  many  of  the  same  phe- 
nomena as  tuberculous  disease.  But  the  affection  is  far  less  common, 
and  there  is  this  difference :  the  malady  usually  happens  consecutively 
to  an  external  or  an  internal  cancer,  and  scarcely  ever  save  in  persons 
advanced  in  years  ;  there  is  little  or  no  fever,  or,  indeed,  a  subnormal 
temperature,  and  neither  diarrhoea  nor  profuse  sweats.  Pain,  on  the 
other  hand,  or  at  least  attacks  of  spontaneous  pain,  are  more  fre- 
quent ;  the  lymphatic  glands  enlarge ;  and,  as  the  omentum  is  the 
most  common  seat  of  the  cancerous  growth,  we  can  generally  detect 
a  tumor  stretching  across  the  upper  portion  of  the  abdomen.  The 
morbid  mass  is  unequal,  and  usually  discovered  readily,  except  where 
separated  by  fluid  from  the  abdominal  parietes.  There  are  often 
nodules  in  the  neighborhood  of  the  umbilicus  and  enlarged  inguinal 
glands ;  a  peritoneal  friction-sound  is  heard.  Hemorrhage  into  the 
abdominal  cavity  or  the  effusion  of  bloody  serum  occurs  in  cancerous 
as  it  does  in  tubercular  peritonitis.     In  cancerous  peritonitis  the  ascitic 

^  See  case  in  Liverpool  Hospital  Reports,  1868. 


ABDOMINAL  ENLARGEMENT.  615 

fluid  has  a  turbid  gray  look.  In  the  sediment  that  forms  there  is  a 
rich  cell-growth  with  many  red  blood-corpuscles.  The  cells  are  for  the 
most  part  peculiar,  large,  swollen,  nucleated  cells ;  ^  many  are  multi- 
nuclear  cells.  In  primary  cancer  of  the  peritoneum,  or  that  following 
cancer  of  the  retroperitoneal  glands^  the  diagnosis  is  very  obscure,  un- 
less the  tumors  are  marked.  The  cancerous  malady  pursues  a  slowly 
progressive  course,  lasting  months  ;  but  it  may  develop  as  an  acute 
miliary  disease.  Retroperitoneal  tumors  may  be  readily  mistaken  for 
diseases  of  the  liver.  They  may  occasion  jaundice  from  pressure  on 
the  common  duct.  The  fact  that  they  do  not  move  with  the  acts  of 
breatliing,  as  well  as  that  there  is  often  a  line  of  resonance  between 
the  dulness  they  occasion  and  the  liver  dulness,  is  a  point  of  value  in 
diagnosis.^ 

Distention  of  the  Bladder. — This  may  give  rise  to  a  sense  of  fluc- 
tuation and  to  very  marked  abdominal  enlargement ;  so  marked,  in- 
deed, that  patients  have  been  tapped,  under  the  supposition  that  they 
were  laboring  under  dropsy  of  the  alDdomen.  But  when  the  bladder 
is  so  much  distended  as  to  simulate  ascites,  there  is  more  or  less  tender- 
ness on  pressure  over  the  seat  of  the  obvious  swelling ;  which,  more- 
over, presents  a  rounded  outline  of  dulness  on  percussion.  Again,  we 
have  the  history  either  of  retention  or  of  apparent  incontinence  of 
urine.^  But,  to  avoid  all  possible  chance  of  error,  in  any  case  of  doubt 
a  catheter  should  be  introduced  into  the  bladder.  This  mode  of  pro- 
cedure, it  may  here  be  mentioned,  is  the  one  which  leads  most  speedily 
and  decisively  to  a  true  appreciation  of  the  abnormal  phenomena  in 
those  rare  cases  of  anasarca  which  are  produced  by  distention  of  the 
bladder,  and  of  which  Trousseau  has  recorded  several. 

The  Gravid  Uterus. — A  gravid  womb  is  readily  distinguished  from 
abdominal  dropsy  by  the  peculiar  form  of  the  dulness  on  percussion, 
its  steady  and  uniform  increase  corresponding  to  the  enlargement  of 
the  womb,  the  absence  of  fluctuation,  the  detection  of  the  sounds  of 
the  foetal  heart,  the  alteration  in  the  color  and  appearance  of  the 
mammary  areola,  and  the  production  of  movements  in  the  wo-mb  on 
making  an  examination  per  vaginam. 

Chronic  Tympanites. — Great  prominence  of  the  alDdomen,  due  to 
flatulent  distention  of  the  bowels,  is,  if  at  all  persistent,  very  apt  to 

^  Runeberg,  Deutsches  Archiv  f.  klin.  Med.,  Sept.  1883  ;  also  Coe,  New  York 
Med.  Journ.,  July,  1888. 

2  Vander  Veer,  Amer.  Journ.  Med.  Sci.,  Jan.  1892. 

'  In  a  case  recorded  by  Watson,  in  his  Lectures  on  the  Practice  of  Physic, 
although  the  bladder  was  enormously  distended,  large  quantities  of  urine  were 
constantly  passing  from  the  patient. 


616  MEDICAL  DIAGNOSIS. 

be  mistaken  for  ascites.  But  the  large  abdomen  yields  not  a  dull,  but 
everywhere  a  tympanitic  sound,  and  there  is  no  fluctuation.  Then 
the  history  of  the  case  and  the  attending  symptoms  throw  light  upon 
the  nature  of  the  ailment.  Many  persons  suffering  from  chronic  tym- 
panites have  all  the  signs  of  weak  gastric  or  intestinal  digestion ;  in 
others  there  is  hysteria. 

Among  soldiers  this  chronic  tympanites — owing,  perhaps,  in  many 
cases  to  the  character  of  their  diet  and  consequent  digestive  dis- 
turbances— is  far  from  being  an  uncommon  disorder,  and  may  be  a 
very  obstinate  one.  It  gives  rise  to  abdominal  enlargement,  which  is 
constantly  mistaken  for  dropsy,  but  which  does  not  yield  a  sense  of 
fluctuation,  or  return  on  percussion  any  other  than  a  well-marked 
tympanitic  sound.  The  distention  produces,  moreover,  an  inability  to 
take  active  exercise,  sensations  of  cutting  pain  under  the  ribs,  and 
palpitation  of  the  heart ;  pressure  on  the  abdomen  occasions  much 
discomfort ;  the  soldiers,  therefore,  walk  with  their  clothes  unbuttoned, 
and  find  it  very  irksome  to  wear  their  belts.  They  are  sometimes 
troubled  by  indigestion,  and  feel  particularly  uncomfortable  after  meals  ; 
or  the  symptoms  of  indigestion,  although  they  may  have  been  present 
at  the  beginning  of  the  complaint,  disappear,  but  the  swellmg  of  the 
abdomen  persists  for  many  months.  According  to  my  experience,  the 
ailment  is  always  gradual  in  its  development. 

Besides  the  complaints  just  reviewed,  which  are  those  most  com- 
monly confounded  with  ascites,  there  are  a  few  very  rare  disorders 
which  might  be  mistaken  for  collections  of  fluid  in  the  peritoneal  sac. 
They  are  dropsy  of  the  womb ;  dropsy  of  the  Fallopian  tubes  ;  dropsy 
of  the  omentum  ;  very  large  serous  cysts  in  the  kidney ;  hydatids  of 
the  liver,  of  size  so  great  as  to  lead  to  general  abdominal  distention ; 
and  a  dilatation  of  the  stomach  so  extensive  that  the  viscus  occupies 
almost  the  whole  abdomen.  With  reference  to  the  latter  affection  we 
may  distinguish  it  from  ascites  by  the  history  of  the  case  and  the 
vomiting  and  other  marked  gastric  symptoms,  by  the  extended  tym- 
panitic percussion  note,  by  the  indistinct  fluctuation,  which  is  not 
noticed  except  over  the  most  dependent  part  of  the  organ,  by  the 
splashmg  or  the  metallic  or  amphoric  sounds  which  are-  perceived 
when  its  contents  are  agitated,  by  the  length  to  which  the  stomach- 
tube  can  be  introduced,  and  by  the  chemical  examination  of  the  gastric 
contents.  The  other  maladies  mentioned  can  be  separated  only  by 
.taking  into  account  their  history  and  progress,  and  by  laying  stress 
upon  the  absence  of  those  morbid  states  Avhich  generally  cause  ascites, 
and  upon  the  occurrence  of  special  phenomena  which  point  to  the 
structures  implicated. 


ABDOMINAL   ENLARGEMENT.  617 

Partial  Abdominal  EnlargerQent. 

Abdominal  Tumors. — Even  at  the  risk  of  repetition,  it  is  for 
clinical  purposes  a  matter  of  conA^enience  to  point  out  connectedly  the 
relations  an  abdominal  swelling  bears  to  the  normal  structures  of  the 
abdominal  caA"ity,  and  to  consider,  moreover,  the  swelling  as  consti- 
tuting the  starting-point  of  our  diagnosis. 

Let  us  first  examine  into  the  meaning  of  an  abdominal  tumefac- 
tion occupying  solely  or  principally  one  region  of  the  abdomen. 

Right  Hypochondrium. — The  most  usual  cause  of  a  tumor  in  this 
region  is  an  enlargement  of  the  liver.  Sometimes  a  tumor  which  is  in 
the  loW'Cr  part  of  the  right  hypochondrium,  or  proceeds  from  the  ter- 
mination of  this  region,  is  simply  a  displaced  liver,  or  an  affection  of 
the  gall-bladder.  In  the  first  instance,  the  recognition  of  the  disorder 
— such  as  a  pleuritic  effusion — which  has  given  rise  to  the  displace- 
ment ;  in  the  second,  the  history  of  the  case,  the  shape  of  the  swell- 
ing, and  the  symptoms  attending  it, — will  give  us  an  insight  into  its 
cause.  Again,  a  tumor  in  the  parts  mentioned  may  be  due  to  an 
enlarged  kidney,  cancerous  or  cystic,  or  especially  hydronephrosis. 
Careful  examinations  of  the  urine  and  the  history  of  the  case  furnish 
the  most  certain  means  of  discrimination.  Then  we  must  also  bear 
in  mind  that  all  enlarged  kidneys  displace  the  bowel  in  a  particular 
manner;  they  press  it  forward,  and  the.dulness  over  the  tumor  is 
largely  mixed  with  a  tympanitic  sound,  or  the  dulness  is,  indeed,  not 
very  appreciable. 

Left  Hypochondrium. — The  most  usual  tumors  in  this  region  are 
produced  by  enlargement  of  the  spleen.  An  increase  in  size  of  this 
viscus,  if  acute,  is  generally  owing  to  toxaemias,  acute  fevers,  and  bac- 
terial infection,  as  pyaemia,  puerperal  fever,  acute  tuberculosis,  scarlet 
fever,  typhoid  fever,  relapsing  fever,  or  the  malarial  fevers.  The  cause 
of  the  swelling  is  disclosed  by  the  history  of  the  case  and  by  the 
accompanying  symptoms. 

Inflammation  of  the  spleen  is  an  affection  very  difficult  to  recognize. 
The  most  trustworthy  symptoms  are :  pain  in  the  left  hypochondrium, 
radiatmg  as  far  as  the  left  shoulder,  and  augmented  by  pressure  by 
coughing,  and  by  a  deep  inspiration  ;  nausea  and  vomiting ;  fever 
having  irregular  fits  of  exacerbation ;  sometimes  delirium,  dry  cough, 
and  a  sense  of  suffocation.  The  extent  of  the  splenic  percussion 
dulness  is  decidedly  increased,  and,  when  we  are  sure  that  the  spleen^ 
is  not  displaced,  the  suddenly  widened  area  of  dullness  forms  an  im- 
portant element  in  the  diagnosis.  Splenitis  is  rarely  primary,  is  gen- 
erally from  pytemia  and  from  infarcts.      It  is  often  observed  to  be 


618  MEDICAL  DIAGNOSIS. 

connected  with  emboli  from  endocarditis,  and,  these  being  wafted  also 
to  the  kidneys,  albumin  and  blood  are  found  in  the  urine.  When 
suppuration  in  the  spleen  ensues,  of  which  the  general  cause  is  infec- 
tive endocarditis,  the  fever  may  assume  a  hectic  character  and  the 
patient  lose  flesh  rapidly,  while  the  spleen  increases  in  size.  But 
there  is  no  certainty  in  these  signs,  nor,  indeed,  in  any  of  the  signs 
of  splenic  abscess  ;  this  may  be  latent  and  suddenly  rupture  into  the 
abdominal  cavity  or  the  stomach.  Then  there  may  be  abscesses 
around  the  spleen  with  manifestations  similar  to  those  in  its  substance, 
or  to  pyopneumothorax.^  An  acute  enlargement  of  the  spleen  may 
also  be  owing  to  hemorrhage  from  injury. 

Chronic  enlargement  of  the  spleen  may  be  caused  by  hypertrophy, 
by  waxy  disease,  by  leuksemia  and  lymphadenoma,  by  splenic  anaemia^ 
by  a  malignant  growth,  by  hydatids,  by  syphilitic  tumor,  by  congenital 
syphilis,  and  by  structural  changes  from  malaria.  There  are  scarcely 
any  symptoms  characteristic  of  these  states,  except  the  alteration  the 
blood  undergoes,  evinced  often  by  a  diminution  of  the  red  globules 
and  an  increase  of  the  white.  But  this,  as  we  shall  find  in  studying 
the  blood,  depends  very  much  upon  the  special  disease.  Waxy  hue 
of  the  face,  dropsy,  bleeding  from  the  nose,  from  the  stomach,  or 
from  the  intestinal  canal,  and  digestive  disturbances,  though  far  from 
infrequent,  are  also  not  constant  signs.  Death  even  may  result,  as 
from  rupture  of  varices  of,  the  enlarged  viscus,  without  any  other 
manifestations  of  a  lesion  than  increased  size  of  the  organ.^  When 
enlargement  of  the  spleen  has  reached  a  certain  point,  the  organ 
curves  into  the  hypogastric  and  right  iliac  regions,  and  a  notch  or 
notches  may  be  felt  on  its  anterior  and  inner  surfaces.^  Tliis  sign 
may  be  very  valuable  in  distinguishing  the  enlarged  organ  from  cancer 
of  the  kidney,  for  which  it  has  been  mistaken.*  In  some  instances 
enlargement  of  the  spleen  is  hereditary.^ 

Having  determined  the  persistent  swelling  to  be  due  to  the  abnor- 
mal size  of  the  spleen,  we  must  next  endeavor  to  ascertain  the  cause 
of  it.  The  history  of  the  case  and  the  blood  examinations  are  the 
main  elements  in  diagnosis. 

A  fulness  projecting  from  the  left  hypochondrium  towards  the 
umbilical  or  lumbar  region  may  be  owing  io  fecal  accumulations  in  the 
colon.      Although   these   fecal   accumulations  do  not  occur  so  often 

1  Zuber,  Revue  de  Medecine,  Nov.  1882. 

^  Traube,  Virchow's  Archiv,  1869. 

^  Fagge,  Guy's  Hosp.  Rep.,  1868. 

*  Lancet,  July,  1873. 

5  Wilson  and  Stanley,  Clin.  Soc.  Trans.,  1893. 


ABDOMINAL   ENLARGEMENT.  619 

in  or  near  either  hypochondrium  as  they  do  in  the  iliac  regions, 
yet  they  are  not  very  uncommon,  and  we  should  be  on  our  guard 
against  confounding  them  with  organic  disease,  whether  of  the  stomach, 
spleen,  liver,  kidneys,  peritoneum,  or  ovary.  Their  irregular  outline, 
their  doughy  consistence  and  painlessness,  and  attention  to  the  his- 
tory of  the  case  and  to  the  accompanying  disorder  of  the  digestive 
functions,  will  generally  enable  us  to  detect  the  true  nature  of  the 
swelling.  But  we  must  not  lay  too  much  stress  on  the  non-existence 
of  constipation,  for  sometimes  great  irritability  of  the  bowels  or  per- 
sistent diarrhoea  is  kept  up  by  a  large  collection  of  fecal  matter  in  the 
colon,  and  an  irritative  fever  superadded  gives  a  strong  resemblance 
to  typhoid.^  Repeated  attacks  of  colicky  pains  and  soreness  to  the 
touch  are  not  unusual  in  cases  of  extensive  fecal  accumulation,  and 
jaundice  and  anaemia  have  been  also  noticed.  Besides  looseness  and 
mucus,  the  stools  are  apt  to  show  small,  hard,  fecal  masses,  of  leaden 
hue.  In  cases  of  doubt,  laxatives,  especially  castor  oil,  should  be 
employed  before  any  opinion  is  given,  and  with  the  voiding  of  large 
masses  of  faeces  the  tumor  and  the  attending  symptoms  may  disappear. 

As  regards  swellings  of  any  kind  situated  in  either  hypochon- 
drium, or  in  fact  at  any  portion  of  the  upper  third  of  the  abdomen, 
we  should  always  observe  whether  they  are  affected  by  the  act  of  res- 
piration. This  is  a  valuable  sign,  for  if  the  morbid  mass  move  in  con- 
sequence of  the  depression  of  the  diaphragm,  it  is  because  structures 
are  involved,  such  as  the  stomach  and  transverse  colon,  the  liver  or 
spleen,  which  admit  of  some  mobility ;  whereas  a  tumor  that  is  unin- 
fluenced must  appertain  to  a  fixed  part, — for  instance,  to  the  aorta. 

EpigcLstrium. — The  most  common  cause  of  an  epigastric  tumor  is 
cancer  of  the  stomach.  The  swelling  is  then  associated  with  the 
symptoms  already  described. 

But  a  tumor  in  this  region  may  be  also  produced  by  a  disease  of 
the  pancreas.  A  swelling  occasioned  hj  fatty  degeneration^  ov  hy  uni- 
form simple  hardening  of  the  gland^  cannot,  as  a  rule,  be  discerned  at 
the  bedside.  In  pancreatic  fat  necrosis,  the  areas  of  white  necrotic 
tissue  are  usually  also  found  in  the  mesentery  and  in  other  seats  of 
abdominal  fatty  tissue.  There  are  no  diagnostic  signs.  In  chronic 
pancreatitis,  deep-seated  epigastric  pain  and  tenderness  with  colicky 
attacks,  a  large  quantity  of  matter  like  saliva  passed  by  stool,  profuse 
salivation,  sugar  in  the  urine,  colorless  or  fatty  stools,  and  jaundice 
have  been  observed  to  attend  the  appreciable  swelling  extending 
across  the  epigastrium.     The  association  of  chronic  pancreatitis  with 

*  As  in  a  case  seen  with  Dr.  Arthur  V.  Meigs. 


^20  MEDICAL  DIAGNOSIS. 

diabetes  is  close.  Suppuo^ative  pancreatitis^  as  we  know  from  Fitz's 
analysis,  is  much  more  common  in  women  than  in  men.  Though 
often  chronic,  it  may  manifest  itself  by  sharp  epigastric  pain  and 
vomiting,  and  is  not  infrequently  attended  with  chills  and  irregular 
fever.  It  may  last  weeks  or  months.  A  deep-seated  resistance  over 
the  seat  of  the  pancreas  with  circumscribed  peritonitis,  diarrhoea,  and 
slight  jaundice  are  noticed  as  the  case  progresses.  As  regards  cancer, 
which  can  be  recognized  with  more  certainty,  the  most  trustworthy 
symptoms  are  :  a  tumor  in  the  epigastric  region  ;  pain  there  or  in  the 
back,  not  increased  by  the  taking  of  food,  but  usually  augmented  by 
the  erect  posture ;  progressive  emaciation  and  debility ;  an  appetite 
capricious  rather  than  diminished,  and  in  some  instances,  indeed,  a 
ravenous  desire  for  food;  constipation,  and  at  times,  but  far  from  in- 
variably, fatty  stools,  or  fat-crystals  in  abundance  in  the  grayish  stools,^ 
and  profuse  salivation.  Besides  these  indications,  we  commonly  fmd, 
as  the  disease  advances,  obstinate  jaundice  and  occasional  vomiting. 
Many  of  these  phenomena  belong  also  to  cancer  of  the  stomach ; 
in  truth,  we  never  can  be  certain  of  the  existence  of  the  pancreatic 
malady  until  we  have  excluded  the  gastric  affection.  In  a  differential 
diagnosis  of  this  kind,  the  early  presence  and  habitual  occurrence  of 
vomiting  after  meals,  the  sour  eructations,  the  haematemesis,  the  want 
of  free  hydrochloric  acid  in  the  stomach-contents  with  the  presence 
of  lactic  acid,  and  the  absence  of  jaundice,  assist  us  in  locating  the 
seat  of  the  disease  in  the  stomach.  A  cyst  of  the  pancreas  is  distin- 
guished by  a  smooth  round  tumor  in  the  epigastrium,  slightly  movable, 
and  separated  by  tympanitic  percussion  resonance  from  the  liver  and 
spleen.  When  the  stomach  is  inflated,  the  tumor  is  found  to  lie 
behind  and  below  it.  If  the  cyst  be  aspirated,  an  alkaline  fluid  is 
obtained  which  emulsifies  fat,  transforms  starch  into  glucose,  and  may 
digest  albumin  and  fibrin.  Calculous  disease  of  the  pancreas  is  a  very 
rare  affection.  There  are,  in  addition  to  the  dull  sense  of  weight  at 
the  epigastrium  and  other  symptoms  of  pancreatic  disease, — such  as 
the  intermittent  presence  of  sugar  in  the  urine,  vomiting,  the  passage  of 
much  undigested  muscular  fibre,  and  of  fatty  stools, — sharp,  irregular 
attacks  of  colicky  pain  radiating  to  the  left,  due  to  the  passage  of 
calculi ;  there  is  no  jaundice.^ .  Pancreatic  calculi  may  lead  to  atrophy 
of  the  gland  and  become  associated  with  permanent  diabetes.^ 

1  But  collections  of  fat-crystals,  Gerhardt  has  found,  are  also  detected  in  the 
pale  stools  of  icterus  without  pancreatic  disease  ;  when  the  bile  reappears  in  the 
stools  the  crystals  are  no  longer  seen. 

^  Fitz,  "Diseases  of  the  Pancreas,"  AUbutt's  System  of  Medicine. 

^Lichtheim,  Berlin,  klin.  Wochensch.,  1894,  No.  8. 


ABDOMINAL  ENLARGEMENT.  621 

An  epigastric  tumor  is  sometimes  simulated  by  a  contraction  of  the 
upper  portion  of  the  rectus  muscle  on  palpation  ;  but  the  swelling  soon 
subsides,  especially  if  rubbed.  Occasionally,  however,  a  tumefaction 
due  to  contraction  of  an  abdominal  muscle  may  be  of  some  duration.^ 
I  have  known  a  contraction  of  the  rectus  muscle  in  a  case  of  gastric 
cancer  occasion  so  obvious  a  resistance  and  swelling  that  it  was  looked 
upon  as  due  to  malignant  disease  of  the  intestine  or  of  the  peritoneum. 
Moreover,  the  rigid  muscle  gave  rise  to  dulness  on  percussion.  But, 
though  the  phenomena  were  for  a  long  period  a  marked  feature  of  the 
case,  it  was  observable  that  the  muscle  was  raised  and  rigid  to  a  de- 
cided degree  only  in  certain  positions  ;  at  all  events,  that  certain  posi- 
tions gave  a  distinct  outline  to  the  swelling,  and  that  the  latter  then, 
like  the  line  of  dulness,  was  regular  and  straight,  evidently  corre- 
sponding to  the  contour  of  the  muscle.  And  this  occurs  in  all  instances 
of  contraction  of  the  rectus,  no  matter  with  what  associated. 

The  muscular  contractions  are  not  always  confined  to  one  muscle, 
or  to  the  whole  of  one  muscle,  and  when  irregular,  and  particularly 
when  associated  with  tympanitic  distention  of  the  intestine,  give  rise 
to  most  of  the  so-called  "  phantom  tumors"  of  the  abdomen.  These 
swellings  are  perplexing,  and  are  constantly  mistaken  for  serious  ab- 
dominal tumors.  The  history  of  the  case,  the  absence  of  grave  con- 
stitutional symptoms,  the  most  frequent  occurrence  of  the  tumefaction 
in  women,  especially  in  hysterical  women,  and  the  usually  coexisting 
constipation,  furnish  us  with  valuable  signs  of  distinction.  But  I  be- 
lieve the  use  of  anaesthetics  to  be  the  most  important  means  of  diag- 
nosis. I  was  first  led  to  employ  them  a  number  of  years  ago,  in  a 
case  which  had  baffled  the  skill  of  several  eminent  surgeons,  one  of 
whom  had  proposed  to  the  patient  an  operation  as  the  only  means  of 
relief  from  what  was  considered  an  ovarian  disease.  The  patient  was 
thirty-one  years  of  age,  a  widow,  and  evidently  of  highly  hysterical 
temperament.  She  was  very  subject  to  constipation  ;  and  the  swelling 
of  which  she  complained  was  of  irregular  outline  and  occupied  the 
centre  of  the  abdomen,  extending  some  distance  on  each  side  of  the 
median  line.  It  was  hard  and  resisting  to  the  touch,  but,  on  strong 
percussion,  yielded  a  tympanitic  sound.  Whenever  it  was  touched  she 
shrank.  Thorough  relaxation  was  produced  by  the  administration  of 
ether ;  the  hand  could  be  pressed  almost  against  the  vertebral  column, 
and  all  signs  of  the  tumor  disappeared.  A  complete  recovery  took 
place ;  and  thus  terminated  a  case  which  had  lasted  for  fully  one  year. 
In  any  instance  of  phantom  tumor  I  would  recommend  the  use  of 


^  Greenhow's  cases,  Lancet,  1857. 
39 


(322  MEDICAL  DIAGNOSIS. 

anaesthetics  for  purposes  of  diagnosis  ;  nay,  they  may  be  most  advan- 
tageously employed,  for  similar  reasons,  in  all  cases  of  abdominal 
swelling  in  which  the  rigid  state  of  the  abdominal  walls  interferes 
with  accuracy  of  investigation.  Fitz^  regards  the  chronic  phantom 
tumor  as  identical  with  idiopathic  dilatation  of  the  colon,  and  the  latter 
as  the  constant  characteristic. 

In  soldiers  we  obser^^e  at  times  one  or  several  small  movable 
tumors,  yielding  a  tympanitic  sound  on  percussion,  in  the  epigastric 
or  at  the  upper  part  of  the  umbilical  region.  They  are,  probably, 
small  portions  of  intestine  which  have  been  pushed  between  the 
fasciculi  of  a  ruptured  rectus  muscle,  similar  to  umbilical  hernia. 

Umbilical  Region. — Tumors  which  are  found  in  this  region  form, 
as  a  rule,  merely  portions  of  a  swelling  that  is  principally  seated  in  the 
epigastrium  or  in  the  hypochondria,  such  as  cancer  of  the  stomach, 
of  the  liver,  of  the  pancreas,  or  of  the  omentum,  and  dilatation  of  the 
gall-bladder.  The  only  two  affections  which  are  apt  to  occasion  a 
swelling  solely,  or  at  least  principally,  limited  to  and  perceptible  m  the 
umbilical  region,  are  tuberculous  disease  of  the  mesenteric  glands  and 
a  movable  kidney. 

The  symptoms  of  the  former  malady,  or  tahes  mesenterica^  are 
much  the  same  as  those  of  tubercular  peritonitis.  Indeed,  unless  the 
enlarged  mesenteric  glands  can  be  felt  through  the  abdominal  parietes, 
the  discrimination  is  uncertain.  The  abdomen  is  prematurely  large, 
is  slightly  tender  on  pressure,  and  has  often  a  doughy  feel ;  the  child 
loses  flesh,  the  digestion  is  impaired,  the  evacuations  are  frequent, 
liquid,  and  offensive.  It  often  presents  signs  of  scrofulous  or  tuber- 
cular disease  elsewhere  ;  and  under  such  circumstances  we  cannot  be 
at  a  loss  in  determining  the  nature  of  the  tumefaction  in  the  umbilical 
region.  The  disease  is  very  rare  in  adults,  though  it  occurs.^  Its 
simulation,  especially  in  young  women,  by  pseudo  tabes  mesenterica, 
has  been  described  in  reviewing  the  affections  of  the  stomach. 

When  the  kidneys  are  not  firmly  held  by  their  attachments,  they 
become  displaced,  and  are  apt  to  give  rise  to  serious  errors  in  diag- 
nosis. The  dislocated  organ  is  perceived  under  the  margin  of  the 
ribs  on  the  right  flank,  or  in  the  umbilical  region,  and  sometimes 
extends  across  the  median  line.  The  mass  is  easily  moved,  may 
be,  by  careful  and  methodical  pressure,  returned  to  tbe  renal  region, 
and  presents,  on  palpation  and  on  percussion,  the  outline  of  the  kid- 
ney.    The  lumbar  region  yields  a  tympanitic  sound  on  percussion, 

^  American  Journal  of  the  Medical  Sciences,  Aug.  1899. 
^  See  case  reported  by  Gairdner,  Lectures  to  Practitioners. 


ABDOMINAL  ENLARGEMENT.  623 

and  we  find  less  resistance  and  a  slight  depression  over  the  usual  seat 
of  the  organ.  But  the  most  certain  way  of  detecting  a  movable  kidney 
is  to  examine  the  patient  by  palpation  with  both  hands,  while  in  the 
recumbent  position  with  the  abdominal  walls  relaxed,  and  on  deep 
inspiration  the  fingers  of  the  right  hand  will  then  feel  the  resistance 
and  the  outline  of  the  kidney.  There  is  in  some  instances  sensitive- 
ness over  the  displaced  organ,  especially  after  fatigue  or  strong  press- 
ure ;  and  this  occasions  the  same  sensation  as  when  the  renal  region 
of  the  non-affected  side  is  pressed ;  but  w^e  do  not  find  any  disturb- 
ance of  the  urinary  functions,  save,  perhaps,  frequent  urination,  nor, 
in  fact,  except  a  disagreeable  feeling  in  walking,  does  any  real  incon- 
venience result  from  the  accident,  unless  the  movable  kidney  has 
become  painful,  or,  by  compressing  the  vena  cava  or  portal  veins, 
occasions  dropsy.  Yet  we  meet  with  exceptions  to  the  rule  that  the 
disorder  gives  rise  to  no  decided  symptoms.  Sometimes  dyspepsia, 
especially  nervous  dyspepsia,  is  pronounced,  as  well  as  intercostal 
neuralgia.  The  stomach  is  often  below  the  normal  level.  So-called 
gastric  crises  also  occur,  marked  by  constipation,  a  feeling  of  weight 
in  the  abdomen,  pain  in  the  sacral  region  after  exertion,  throbbing  of 
the  abdominal  aorta  and  vomiting,  with  severe  abdommal  pain  and 
fever ;  or  there  are  attacks  simulating  renal  colic.  Further,  we  may 
find  intermitting  hydronephrosis.^  In  certain  instances  the  pressure 
on  the  bile-ducts  from  a  displaced  right  kidney  gives  rise  to  attacks  of 
hepatic  colic  followed  by  jaundice,  and  leads  to  the  supposition  of  gall- 
stones.- There  seems  to  be  a  special  connection  between  movable  kid- 
ney and  neurasthenic  hysteria,  gastric  dilatation,  enteroptosis,  chronic 
appendicitis  of  the  right  side,^  and  membranous  enteritis,  but  the 
majority  of  cases  are  latent,  and  are  only  accidentally  detected. 

The  disorder  is  most  apt  to  occur  after  violent  exertion,  or  after  many 
pregnancies,  or  may  be  due  to  attacks  of  congestion  of  the  organ,  or  to 
tight  lacing.  It  is  rare  in  men.  The  right  kidney  is  oftener  movable 
than  the  left,  and  it  may  be  felt  low  down  as  a  movable  mass  floating 
near  the  right  iliac  fossa.     Both  kidneys  may  be  displaced. 

The  affection  may  be  mistaken  for  any  form  of  abdominal  tumor, 
and  if  the  kidney  should  have  become  adherent  the  diagnosis  is  un- 
certain. Generally  the  disorder  -can  be  distinguished  by  the  history  of 
the  case,  and  by  the  physical  phenomena  mentioned.  To  these  may 
be  added  the  comparatively  slight  dulness  or  rather  the  tympanitic 

1  Knight,  Lancet,  Oct.  1893. 

^  Maclagan  and  Treves,  Lancet,  Jan.  6,  1900. 

=>  Edebohls,  Medical  Record,  March,  1899. 


624  MEDICAL  DIAGNOSIS. 

character  of  sound  elicited,  except  on  very  strong  percussion,  over  the 
seat  of  the  tumor.  This  is  an  important  fact  as  regards  the  discrim- 
ination of  a  movable  and  disj)laced  spleen,  in  which,  as  the  organ  is 
generally  enlarged,  there  is  extended  dulness  on  percussion.  More- 
over, the  history  of  the  splenic  disorder,  which  not  uncommonly  can 
be  traced  to  a  malarial  affection,  the  usually  great  tenderness,  the 
nausea,  dyspeptic  symptoms,  and  hemorrhagic  tendencies  which  at- 
tend the  displacement  of  the  spleen,  and  the  notch  which  can  be  felt 
in  it,  will  assist  us  in  our  diagnosis.  A  movable  kidney  may  be  simu- 
lated by  malignant  disease  of  the  colon} 

Yet  another  of  the  abdominal  organs  is  occasionally  displaced  and 
movable, — the  liver.  Now,  a  movable  liver  would  be  often  mistaken 
for  a  movable  spleen,  were  it  a  more  common  affection.  But  few 
well-authenticated  cases  are  on  record.^  In  these  the  peritoneal 
attachment  of  the  organ  had  become  lax,  usually  in  consequence  of 
pregnancy  ;  in  the  hepatic  region  there  was  a  tympanitic  sound  on 
percussion  ;  and  in  the  umbilical  region  and  towards  the  right  flank  a 
solid  body  was  discerned,  the  upper  border  of  which  presented  a 
convex  outline,  the  lower  border  was  in  the  inguinal  region.  The 
displaced  organ  was  easily  pushed  about,  and  could  be  replaced  in 
its  proper  situation.  The  spleen  was  found  in  its  usual  seat ;  the 
symptoms  were  merely  those  of  weight  and  uneasiness  in  the  abdo- 
men. The  movable  or  wandering  organ  may  be  painful  or  painless. 
It  has  the  physical  characters  of  the  liver,  and  the  most  certain  sign 
is  the  detection,  on  palpation,  of  the  notch  between  the  right  and  the 
left  lobe  and  of  a  zone  of  tympanitic  resonance  between  the  swelling 
and  the  lung.  The  diagnosis  is,  however,  always  difficult  and  doubt- 
ful. New  growths  of  the  kidney,  as  a  case  of  Legg's  proves,  are  par- 
ticularly confusing.  In  most  recorded  cases  autopsies  are  wanting ; 
and  the  whole  subject  is  very  obscure.  The  affection  is  more  usual 
in  women  than  in  men,  and,  besides  pregnancy,  tight  lacing  and 
chronic  inflammation  of  the  peritoneum  are  said  to  lead  to  it. 

Lumbar  Region. — Tumors  in  this  region,  or  on  either  flank,  are 
occasioned  by  some  morbid  growth  of  the  kidney,  or  by  an  abscess  in  it 
or  its  surroundings,  or  in  the  psoas  muscles.     Again,  they  may  be  due 

^  Henry  Morris,  Lancet,  April,  1896. 

^  See  Cantani,  Ann.  Univers  di  Medicina,  1866  ;  and  Meissner's  article  in 
Schmidt's  Jahrb.,  1869,  No.  1  ;  alsoibid.,  No.  2,  1871  ;  Blet,  Le  Foie  mobile,  These 
de  Paris,  1876  ;  Legg,  St.  Bartholomew's  Hospital  Reports,  1877  ;  Arini,  Anales  del 
Circulo  Med.  Argentine,  quoted  in  Amer.  Journ.  Med.  Sci.,  July,  1884  ;  H.  W.  Sea- 
ger,  Brit.  Med.  Journ.,  London,  1885,  ii.  ;  L.  Landau,  Deutsche  Med.  Wochensch., 
Berlin,  1885,  ii.  ;  Richelot,  L'Union  Medicate,  Paris,  Aug.  1893. 


ABDOMINAL  ENLAEGEMENT.  625 

to  fecal  accumulations  ;  or,  if  on  the  right  side,  to  very  considerable  in- 
crease of  the  liver  ;  if  on  the  left,  to  a  greatly  enlarged  spleen.  To  dis- 
criminate between  these  conditions,  we  have  to  determine  whether  the 
swelling  fluctuates  or  not ;  we  must  also  analyze  the  urine,  and  inquire 
minutely  into  the  circumstances  preceding  and  attending  the  tumefaction. 
It  is  thus  only  that  we  can  attain  the  necessary  data  for  a  diagnosis, 
which  has,  indeed,  often  to  be  reached  by  the  process  of  exclusion. 

Tumors  behind  the  peritoneum  may  give  rise  to  a  visible  promi- 
nence in  either  lumbar  region,  extending  to  the  upper  part  of  the  iliac 
region.  The  most  common  cause  of  these  tumors  is  cancer  of  the 
lymphatic  glands  lying  by  the  sides  or  in  front  of  the  vertebral  column. 
The  disease  is  very  difficult  of  detection.  Still,  we  may  suspect  its 
existence  if,  in  a  patient  who  is  evidently  cachectic  and  who  is  steadily 
losing  flesh  and  strength,  we  discover,  on  deep  palpation,  on  one  side 
of  the  linea  alba  or  in  the  flank,  a  tumor  which,  owing  to  its  being 
surrounded  by  intestine,  returns  a  tympanitic  percussion  sound.  In 
some  cases  the  swelling  communicates  the  beat  of  the  aorta  and  sim- 
ulates an  aneurism,  or  it  presses  on  the  vena  cava  and  gives  rise  to 
enlargement  of  the  abdominal  veins  and  of  those  of  the  lower  ex- 
tremities, and  to  cEdema  of  the  legs.  The  disease  may  involve  the 
iliac  glands  and  the  tumor  extend  into  the  pelvis,  or  it  may  reach  up- 
ward to  the  diaphragm  ;  and,  by  the  cancer  spreading  to  the  posterior 
mediastinum,  it  may  finally  open  the  aorta,  producing  hemorrhages 
precisely  like  those  coming  from  an  aneurismal  sac.^ 

Iliac  Regions. — Tumors  in  either  of  these  regions  may  be  due  to 
many  different  causes.  They  are,  as  we  have  elsewhere  discussed, 
principally  owing  to  ovarian  affections  ;  to  fecal  accumulations ;  to 
disease  of  the  large  intestine,  such  as  intussusception  or  cancer  ;  and 
to  pelvic  abscess.  Sometimes  they  are  caused  by  displacement  of  the 
kidney,  by  enlargement  of  the  spleen,  and  in  women  by  retrouterine 
hsematocele,  or  by  extrauterine  pregnancy. 

The  ovarian  tumors  are,  as  a  rule,  distinguished  from  the  other 
disorders  mentioned  by  their  more  or  less  globular  form,  by  their 
movability  from  side  to  side  or  in  an  upward  direction,  by  their  seem- 
ing to  spring  out  of  the  pelvis,  and  their  evident  attachment  below, 
by  the  displacement  of  the  wo.mb,  by  the  comparatively  unimpaired 
general  health,  and  by  their  indolent  and  generally  painless  nature. 
These  remarks  do  not  apply  to  the  very  slight  swelling  occasioned  by 
ovarian  inflammation,  for  here  the  tumid  spot  is  often  the  seat  of 
severe  pain.     The  healthy  ovary  is  not  sensitive  to  the  touch.     To 

^  Case  reported  by  Haldane,  Edinburgh  Medical  JournalJ  Aug.  1868. 


626  MEDICAL  DIAGNOSIS. 

examine  the  ovary  with  exactness,  the  abdominal  muscles  must  be 
completely  relaxed  ;  the  patient  is  placed  in  the  attitude  recommended 
by  Marion  Sims, — on  her  back,  with  the  shoulders  supported,  the  legs 
drawn  up  so  that  the  heels  are  a  few  inches  asunder  and  the  thighs 
fall  easily  apart. 

As  ovarian  tumors  grow  and  spread  upward  they  give  rise  to  diffi- 
culties in  diagnosis,  which  we  have  already  examined  into.  We  may 
here  again  mention  the  manner  in  which  ovarian  may  simulate  renal 
groivths.  Stress  may  be  laid  on  the  renal  tumor  being  first  detected 
between  the  false  ribs  and  the  ilium  ;  on  the  signs  in  the  urme,  and  on 
the  absence  of  those  changes  in  the  quantity  and  regularity  of  the 
menstrual  discharge  Avhich  are  common  in  ovarian  disorders.  More- 
over, the  ovarian  growth  usually  displaces  the  intestine  backward ;  in 
the  renal  growth  it  is  pressed  forward  and  towards  the  centre  of  the 
abdomen ;  and  large  tumors  of  the  right  kidney  ordinarily  have  the 
ascending  colon  on  their  inner  border,  while  tumors  of  the  left  kidney 
are  generally  crossed  from  above  downward  by  the  descending  colon. 

Among  the  causes  of  a  tumor  in  either  iliac  fossa,  retrouterine 
hcematocele  has  been  mentioned.  The  tumor,  commonly  of  rounded 
shape,  rises  above  the  brim  of  the  pelvis,  but  is  traceable  into  it.  It 
forms  quickly,  and  an  examination  through  the  vagina  detects  a  boggy 
swelling  in  Douglas's  cul-de-sac,  and  at  times  the  grating  of  the  blood 
coagula ;  faintness  and  collapse  attend  its  production.  Much  the  same 
physical  phenomena  are  presented  by  the  swelling  due  to  pelvic  cellu- 
litis. But  the  slow  way  in  which  the  tumor  forms,  the  presence  of 
a  hot,  puffy,  brawn-like  condition  of  the  vaginal  wall,  the  usually 
greater  tenderness  of  the  swelling  felt  through  the  walls  of  the  vagina, 
and  the  feverishness  and  constitutional  symptoms  attending  the  grad- 
ual formation  of  the  abscess,  are  distinguishing  marks,  except  where 
the  contents  of  the  hsematocele  suppurate,  when  for  a  differential 
diagnosis  we  may  have  to  rely  on  the  history  of  the  case. 

Hypogastric  Region. — Distention  of  the  bladder  and  enlargement 
of  the  uterus,  whether  produced  by  air,  by  liquid,  by  a  morbid  growth, 
or  by  pregnancy,  are  the  most  usual  sources  of  a  swellmg  in  this 
region.  If  due  to  any  one  of  these  causes,  the  outline  of  the  tumor  is 
regular  and  rounded  ;  and  by  the  aid  of  the  catheter,  of  explorations 
through  the  vagina  and  the  rectum,  of  the  history  of  the  case,  and  of 
the  attending  symptoms,  we  are  generally  enabled  to  arrive  at  a 
correct  diagnosis. 

A  tumor  in  the  hypogastrium  may  also  have  its  origin  in  splenic 
enlargement,  in  diseases  of  the  peritoneum,  or  in  haematocele.  In  the 
latter  case  it  is  apt  to  be  uniform  and  to  extend  to  the  ihac  fossce. 


ABDOMINAL   ENLARGEMENT.  627 

In  concluding  this  sketch  of  abdominal  tumors,  we  shall  briefly 
glance  at  those  which  are  likely  to  occupy  more  than  one  region,  and 
sometimes  even  the  whole  or  greater  part,  of  the  abdomen.  In  rare 
instances,  a  cancer  of  the  liver,  or  hydatids  of  that  organ,  or  a  fibrous 
tumor  of  the  uterus,  or  a  solid  ovarian  growth,  or  an  enlarged  spleen,^ 
or  a  kidney  the  pelvis  of  which  has  become  enormously  distended  in 
consequence  of  obstruction  of  the  ureter,  may  lead  to  the  formation  of 
a  swelling  that  occupies  nearly  the  entire  abdomen.  But  the  most 
usual  cause  of  so  diffuse  a  tumor  is  carcinoma  of  the  j^eritoneum.  Here 
there  is  an  irregular  tumor,  pain,  ascites,  and,  in  consequence  of  the 
peritonitis  set  up,  fever.  Much  the  same  symptoms  may  be  produced 
by  hydatid  disease  of  the  peritoneum,  though  there  is  less  fever  or  none, 
the  swelling  may  be  uniform  or  even  more  irregular,  the  abdominal 
enlargement  greater  and  painless,  and  we  may  be  able  to  detect  the 
hydatid  fremitus,  and  the  booklets  in  the  evacuated  fluid.^  Yet  as 
regards  the  hydatid  thrill  we  must  bear  in  mind  that  a  similar  sensa- 
tion is  obtained  from  large  parovarian  cysts  ^  or  from  colloid  cancer  of 
the  peritoneum ;  a  sensation  of  peculiar  and  very  superficial  fluctua- 
tion,* associated,  however,  here  with  grave  symptoms  of  cachexia,  and 
generally  with  a  rapidly  spreading  growth.  Peritoneal  abscesses  en- 
closed by  adhesions  will  also,  if  large,  give  rise  to  several  of  the 
signs  of  a  cancer ;  ■  but  the  history  of  an  antecedent  local  or  gen- 
eral peritonitis,  the  swelling  not  being  influenced  by  changes  in  the 
posture  of  the  patient,  the  irregular  fever,  the  indistmct  fluctuation 
of  the  tumefaction,  and  its  acute  course,  may  enable  us  to  distin- 
guish the  non-malignant  from  the  malignant  affection.  In  rare  in- 
stances a  tumor  may  be  enormous,  increase  rapidly,  yet  be  simply 
fatty.  There  are  no  means  of  positively  distinguishing  the  affec- 
tion.^ Sarcoma  cannot  be  told  from  carcinoma ;  it  is  more  common 
in  advanced  age. 

In  some  cases  the  malignant  disease  is  closely  simulated  by  dila- 
tation of  the  colon,  caused  ordinarily  by  fecal  tumors.  This,  though  it 
may  present  but  a  single  swelling,  generally  occasions  several,  which 
are  commonly  seated  at  the  middle  third  of  the  abdomen,  are  apt  to 

*  As  in  the  case  reported  by  Porter,  Philadelphia  Medical  Times,  June,  1875,' in 
which  the  spleen  weighed  twenty-one  pounds. 

-  See  the  cases  of  Bright,  in  Clinical  Memoirs  on  Abdominal  Tumors,  repub- 
lished from  Guy's  Hospital  Reports  by  the  New  Sydenham  Society. 
'  Bristowe,  St.  Thomas's  Hospital  Reports,  vol.  xi. 

*  As  in  the  instances  recorded  by  Albert  Robin,  Bull,  de  la  Soc.  Anat.,  1873, 
and  Vidal,  Bull,  et  Mem.  Soc.  Med.  des  Hopit.,  1874. 

'"  See  St.  George's  Hospital  Reports,  vol.  v.,  1870,  p.  253. 


628  MEDICAL   DIAGNOSIS. 

appear  on  both  sides,  to  be  movable  and  painless  and  to  bear  handling 
without  pain,  to  change  their  position  slightly  at  inter\^als,  and  to  be- 
come occasionally  less  in  size.  Then,  after  the  case  has  been  for 
some  time  under  observation,  we  may  be  able  to  notice  large  and 
characteristic  discharges ;  though  we  must  not  forget  that  a  mere 
sluggish  state  of  the  bowels,  or  even  diarrhoea,  may  exist  while  the 
colon  is  dilated  and  perhaps  filled  mth  fecal  accumulations.  Some- 
times the  mass  may  be  seated  above  the  symphysis  and  be  mistaken 
for  a  pelvic  tumor.  Like  a  cancerous  growth,  it  may  lead  to  complete 
intestinal  obstruction.  The  tympanites  and  the  dilatation  it  occasions, 
which  may  be  idiopathic,  produce  at  times  fatal  results.^  The  dilata- 
tion may  be  enormous. 

Cancer  of  the  intestine  has  symptoms  similar  both  to  fecal  accumu- 
lation and  to  cancer  of  the  peritoneum.  The  marked  cachexia  and 
the  signs  of  persistent  and  increasing  narrowing  of  the  bowel,  as 
shown  by  the  flattened  faeces,  the  blood  and  pus  in  the  stools,  the  fre- 
quent attacks  of  colicky  pains,  and  the  vomiting,  distinguish  it  from 
the  former  affection.  The  limitation  of  the  swelling,  the  absence  of 
dropsy,  the  character  of  the  stools,  the  frequent  change  in  the  position 
of  the  tumor  and  in  its  distinctness,^  and,  if  it  affect  the  duodenum, 
the  decided  jaundice,  separate  it  from  peritoneal  cancer. 

SECTION  V. 

ABDOMINAL    PULSATION. 

Aortic  Pulsation. — By  far  the  most  frequent  cause  of  a  pulsation 
visible  in  the  abdomen,  and  especially  at  the  epigastric  region,  is  a 
throbbing  of  the  abdominal  aorta.  It  is  common  m  neurasthenics  and 
hysterical  persons.  Some  women  are  liable  to  it  immediately  before 
their  menstrual  periods  or  during  the  earlier  months  of  pregnancy. 
In  men  it  is  seen  most  often  in  those  who  suffer  from  inveterate  dys- 
pepsia, and  is  apt  to  come  on  in  severe  paroxysms,  which  are  alarm- 
ing to  the  patient,  but  which  generally  disappear  under  brisk  purging. 
In  hypochondriacs  whose  abdominal  walls  are  thin,  the  beating  at 
the  epigastrium  may  become  a  source  of  continued  distress.  The  m- 
creased  action  of  the  aorta,  or,  as  happens  in  emaciated  persons,  the 
greater  distinctness  with  which  the  beat  of  the  artery  is  perceived 

^  Gee,  St.  Barthol.  Hosp.  Rep.,  vol.  xx.  ;  A.  Money  and  S.   Paget,  Clin.   Soc. 
Transact.,  1888;  Formad,  Trans.  Coll.  Physicians,  Phila.,  1892. 
^  Leube,  Ziemssen's  Cyclopaedia. 


ABDOMINAL  PULSATION.  629 

without  there  being  abnormal  throbbing,  may  be  distinguished  from 
an  enlarged  and  somewhat  displaced  heart  by  the  circumstances  of 
the  case  and  the  absence  of  the  physical  signs  of  cardiac  disease  : 
and  from  an  aneurism  by  the  want  of  the  signs  that  characterize  an 
aneurism. 

Abdominal  Aneurism. — Aneurism  of  the  abdominal  aorta  is  a 
disease  of  middle  life,  and  of  males  especially.  Its  most  frequent 
cause  is  excessive  muscular  exercise  ;  sometimes  it  is  produced  by  a 
blow  on  the  abdomen,  or  by  syphilis.  Its  duration  is  very  uncertain  ; 
occasionally  six  or  seven  years  elapse  from  its  earliest  indications  until 
the  fatal  termination  ;  not  unusually  the  patient  lives  twenty  to  thirty 
months  after  its  occurrence. 

The  chief  symptoms  are  pain,  and  an  absence  of  dropsy,  of  fever, 
or  of  any  considerable  constitutional  disturbance.  The  pain  is  gener- 
ally felt  in  the  back,  or  in  the  right  hypochondrium,  or  shooting  down 
the  sciatic  nerves  to  the  lower  limbs.  It  may  be  constant  and  dull,  or 
occur  in  protracted  and  violent  paroxysms  ;  ordinarily  there  is  a  per- 
sistent pain  which  has  periods  of  fierce  exacerbation.  The  dispropor- 
tion between  its.  violence  and  the  otherwise  almost  unimpaired  health 
is  a  striking  feature  of  the  disease,  and  continues  until  the  aneurism 
becomes  very  large  and  occasions  displacement  of  important  organs. 
Besides  pain,  vomiting  and  hiccough  are  sometimes  prominent  symp- 
toms. 

The  physical  signs  of  an  abdominal  aneurism  are :  an  impulse 
communicated  to  the  hand  when  placed  over  the  swellmg ;  a  systolic 
blowing  sound  ;  a  thrill ;  and  in  some  instances  a  distinct  prominence 
and  alteration  in  the  form  of  the  abdomen.  The  impulse  corresponds, 
with  rare  exceptions,  to  the  beat  of  the  heart,  is  single,  and  ordinarily 
very  forcible.  Generally  it  cannot  be  felt  from  behind ;  it  is  a  beat 
discerned  only  anteriorly  and  on  either  side  of  the  pulsating  sac. 
With  the  expansion  of  the  tumor,  we  hear  a  short  blowing  sounds 
both  posteriorly  and  anteriorly,  sometimes  perceived  in  the  recum- 
bent posture  only  ;  or  a  dull,  muffled  sound ;  rarely  are  there  two 
sounds.  A  thrill  felt  at  the  same  time  as  the  pulsation  is  noticed ; 
still,  it  may  be  absent,  even  in  large-sized  aneurisms.  The  pulse  in 
the  femoral  is  often  retarded. 

Aneurism  of  the  abdominal  aorta  may  be  confounded  with — 

Rheumatism  ;  Neuralgia  ;  Colic  ; 

Disease  of  the  Spine  ; 

Aortic  Pulsation  ; 

Lumbar  and  Psoas  Abscess  ; 

Non-Aneurismal  Pulsating  Tumor. 


630  MEDICAL  DIAGNOSIS. 

The  first  four  of  these  affections  are  likely  to  be  mistaken  for  an 
abdominal  aneurism,  on  account  merely  of  the  pain ;  the  others,  be- 
cause of  the  presence  of  pulsation,  or  of  a  swelling,  or  of  both  pulsa- 
tion and  swelling. 

Rheumatism;  Neuralgia;  Colic. — The  pain  caused  by  an  aneurism 
may  closely  simulate  rheumatism  of  the  lumbar  muscles,  or  sciatica, 
or  abdominal  neuralgia,  or  colic.  There  is  nothing  in  the  pain  itself 
which  will  lead  to  the  deteetion  of  its  origin :  this  can  be  effected  only 
by  a  recognition  of  the  physical  signs  of  the  aneurism.  Yet,  abdom- 
inal pain,  or  abdominal  neuralgia,  especially  when  obstinate,  must 
always  make  us  very  suspicious  of  an  aneurism.  In  doubtful  cases 
a  skiagraph  may  prove  of  much  value. 

Disease  of  the  Spine. — Patients  who  are  suffering  from  aneurism 
often  complain  of  pain  in  the  spine,  and  present  sometimes  an  ob\4ous 
spinal  curvature.  But  a  careful  examination,  by  detecting  the  physical 
signs  of  an  aneurism,  will  enable  us  generally  to  distinguish  the  source 
of  the  difficulty.  The  constant  bormg  pain  so  much  complained  of  in 
cases  of  aneurism  is  usually  thought  to  be  due  to  absorption  of  the 
vertebrte,  but  it  has  no  necessary  connection  with  this  lesion. 

Aortic  Pidsation. — Simple  abdominal  pulsation,  such  as  we  observe 
in  neurasthenia,  hysteria,  in  dyspepsia,  in  pregnancy,  and  in  movable 
kidney  ;  or  excessive  epigastric  pulsation  due  to  an  enlarged  right  ven- 
tricle or  to  insufficient  aortic  valves,  may  be  readily  mistaken  for  an 
aneurism.  But  in  the  former  case  the  history  will  generally  lead  us  to  a 
correct  conclusion,  especially  if  taken  in  connection  "with  the  facts  that 
the  pulsation  is  not  heavy  and  slow,  as  in  an  aneurism,  but  jerking  and 
sudden  ;  that  there  is  no  thrill ;  no  tumor  with  corresponding  dulness 
on  percussion,  if  we  except  pregnancy ;  no  systolic  murmur  audible 
in  front  of  the  alDdomen  or  along  the  spine  ;  and  no  pain. 

The  pulsation  due  to  disease  of  the  heart  is  discriminated  by  the 
physical  signs  in  the  thorax.  Regurgitation  at  the  aortic  orifice,  which 
is  the  cardiac  affection  most  liable  to  be  confounded  mth  an  aneurism, 
on  account  of  the  marked  pulsation  it  may  occasion  in  the  left  hypo- 
chondrium  or  at  the  anticardium,  is  distinguished  by  the  single  or 
double  blowing  sounds,  which  are  heard  not  only  over  the  thorax, 
but  also  over  many  arteries  of  the  body,  and  by  the  character  of  the 
pulse. 

Lumbar  and  Psoas  Abscess. — In  some  cases,  soft,  fluctuating,  deep- 
seated  tumors,  that  are  really  produced  by  an  aneurism,  may  arise  in 
the  lumbar  region  ;  nay,  they  may  seem  to  point,  like  a  psoas  abscess, 
at  Poupart's  ligament.  But,  unlike  an  abscess,  the  effusions  of  blood 
give  rise,  with  rare  exceptions,  to  impulse  and  to  murmur. 


ABDOMINAL  PULSATION.  631 

Non-Aneurismal  Pulsating  Tumors. — When  a  tumor  of  any  kind 
presses  upon  the  aorta,  a  distinct  pulsation  is  communicated,  and  the 
similarity  to  an  aneurism  is  heightened  by  the  circumstance  that  the 
morbid  growth  may  produce  a  murmur.  The  tumors  which  most 
usually  occasion  the  phenomena  mentioned  are  :  enlargement  of  the 
left  lobe  of  the  liver,  cancer  of  the  pylorus,  disease  of  the  pancreas,  or 
of  the  omentum,  or  of  the  mesentery,  and,  in  rarer  instances,  enlarge- 
ment of  the  kidney,  fecal  accumulations,  and  cancer  of  the  lumbar 
glands.  To  avoid  error,  we  must  pay  close  attention  to  the  history  of 
the  disorder  and  the  attending  gastric  and  renal  symptoms ;  we 
must  trace,  by  percussion,  the  outline  of  the  solid  mass,  and  see  if 
it  correspond  with  any  viscus.  Then,  in  non-aneurismal  tumor  the 
patient  has  almost  always  been  in  bad  health  before  the  tumor  is 
detected,  and  the  swelling  rarely  causes  pain  of  such  severity  as  is 
observed  in  an  aneurism ;  moreover,  the  transmitted  aortic  impulse 
is  lessened  by  placing  the  patient  on  his  hands  and  knees,  thus 
takmg  away  the  pressure  from  the  artery.  A  varicose  state  of  the 
epigastric  veins  and  the  existence  of  ascites  will  also  decide  against 
an  aneurism ;  while,  on  the  other  hand,  the  lateral  as  well  as  the 
forward  direction  of  the  impulse,  violent  neuralgic  pains  in  the  loins 
or  shooting  down  the  back,  and  an  immovable  tumor,  are  in  its  favor. 
Still,  there  are  cases  in  which  a  morbid  growth  lying  across  the  aorta 
occasions  symptoms  so  nearly  like  those  of  an  aneurism  that  the  most 
skilful  diagnostician  finds  himself  in  doubt ;  or  cases  of  aneurism  in 
which  the  physical  signs  are  absent,  and  in  which  the  affection  affords 
no  indication  of  its  existence,  beyond,  perhaps,  pain.  Under  these 
circumstances  we  can  only  suspect  its  occurrence. 

But  supposing  that,  from  the  combination  of  the  physical  signs 
and  symptoms,  we  know  that  we  are  dealing  with  an  abdominal  aneu- 
rism, can  we  be  sure  that  it  is  aortic  ?  We  cannot ;  for,  although  this 
is  generally  its  seat,  an  aneurism  of  the  splenic  or  the  coeliac  artery, 
of  the  superior  mesenteric  artery,  or  of  the  renal  artery,  may  pro- 
duce the  same  phenomena.^ 

When  an  aneurism  bursts,  it  gives  rise  to  symptoms  which  vary 
with  the  seat  of  the  rent.  The  accident  is  always  fatal,  but  death  may 
not  follow  for  several  days  ;  usually  great  tenderness  of  the  abdomen 
and  changes  in  the  physical  signs  are  at  once  produced. 


See  Ballard,  Physical  Diagnosis  of  Diseases  of  the  Abdomen,  p.  217. 


CHAPTER    VII. 

ON   THE   URINE,    AND   ON   DISEASES   OF   THE   URINARY    ORGANS. 

URINE. 

The  urine,  besides  being  the  most  accurate  index  of  the  condition 
of  the  urinary  organs,  becomes  a  fair  indication  of  that  of  many  other 
important  secreting  glands  in  the  body.  To  glean  the  full  benefit 
from  an  analysis  of  the  urine,  we  must  explore  it  not  merely  quali- 
tatively, but  quantitatively,  and  examine  its  deposits  with  the  micro- 
scope. Modern  chemistry  is  especially  endeavoring  to  find  means 
which  will  determine,  by  apt  volumetric  processes,  the  exact  propor- 
tion of  the  ingredients  as  accurately  and  as  easily  as  hitherto  we  have 
detected  their  presence.  This  is  a  subject  which  cannot  be  more  than 
indicated  in  these  pages :  only  such  of  these  investigations  will  be 
noticed  as  have  furnished  results  which  may  be  made  readily  avail- 
able for  the  exigencies  of  professional  life. 

It  is  customary,  in  quantitative  analyses,  to  use  the  French  system 
of  measures,  and  to  employ  instruments  on  which  cubic  centimetres 
are  marked.  One  thousand  cubic  centimetres  are  equal  to  one  litre, 
or  2.1  pints,  or  to  a  thousand  grammes  of  water ;  and  one  gramme  is 
equal  to  15.434  grains  ;  one  centigramme  to  .1543  of  a  grain. 

Urine,  in  its  normal  state,  is  an  amber-yellow  fluid,  of  acid  reac- 
tion, and  specific  gravity  of  1016  to  1020  as  compared  with  distilled 
water  at  1000.  On  standing  from  eight  to  twelve  hours,  a  slight 
cloudy  deposit  takes  place,  consisting  mainly  of  mucus,  epithelial  cells 
from  the  urinary  passages,  and  a  few  crystals.  Normal  urine  freshly 
voided  contains  no  bacteria,  and  is  aseptic. 

Ordinarily,  urine  soon  undergoes  decomposition,  which  renders 
the  results  of  analysis  valueless.  It  is  advisable,  therefore,  to  exam- 
ine every  specimen  promptly,  but,  as  this  cannot  always  be  done,  the 
addition  of  some  preservative  may  be  needed.  Chloroform  seems  to 
be  the  most  suitable  ;  six  or  eight  drops  added  to  each  fluidounce,  the 
mixture  to  be  well  shaken,  will  preserve  samples  for  months,  even  in 
hot  weather.  Chloroform  gives  a  strong  reaction  similar  to  sugar  with 
Trommer's  test,  but  does  not  reduce  bismuth  subnitrate  nor  interfere 

632 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     633 

with  the  phenylhydrazin  test.  It  arrests  tlie  fermentation  of  sugar 
and  of  urea. 

In  the  examination  of  sediments  great  advantage,  both  as  to  time 
and  complete  collection  of  the  suspended  matters,  is  gained  by  the  use 
of  a  centrifugal  machine,  several  forms  of  which  are  now  procurable. 
The  electric  centrifuge  is  the  most  convenient.  The  centrifugal  method 
tends  to  exaggerate  the  amount  of  material,  as  compared  with  the  old 
method  of  sedimentation,  but  by  it  we  may  obtain  casts  and  suspended 
matter  which  otherwise  would  be  missed.  In  addition  to  its  usefulness 
in  urine-examination,  a  good  high-speed  centrifugal  machine  is  of  much 
use  in  other  clinical  work,  especially  in  examining  sputum  and  blood. 
Purdy's  percentage  tubes  increase  the  advantage  of  the  instrument. 

The  manner  of  obtaining  a  specimen  of  urine  is  not  unimportant. 
We  should  instruct  our  patient,  as  is  so  strongly  recommended  by  Sir 
Henry  Thompson,^  to  pass  the  first  two  ounces  into  one  vessel,  and  the 
remainder  into  another.  We  thus  procure  a  specimen  of  the  renal 
secretion,  in  addition  to  anything  in  the  bladder,  separate  from  any 
urethral  products,  and  avoid  the  error  of  confounding  prostatic  or 
urethral  with  vesical  or  renal  disease;  When  it  is  essential  to  obtain  a 
specimen  of  urine  absolutely  pure  and  unmixed  with  products  of  the 
bladder,  the  same  authority  recommends  the  drawing  off  of  the  urine 
by  means  of  a  soft  gum  catheter,  while  the  patient  is  standing.  The 
bladder  should  then' be  carefully  washed  out  by  repeated  one-ounce 
injections  of  warm  water.  The  urine  is  now  to  be  permitted  to  pass, 
as  it  will  do,  drop  by  drop,  into  a  small  glass  vessel.  The  bladder 
contracts  around  the  catheter,  and  the  urine  percolates  direct  from 
the  ureters,  through  their  virtual  prolongation, — the  catheter, — into 
the  receptacle.  The  urine  passed  in  the  morning,  immediately  after 
rising,  will  be  found  to  represent  with  sufficient  accuracy  the  general 
process  of  disassimilation ;  but,  if  greater  accuracy  be  desirable,  a 
specimen  of  the  mixed  urine  of  the  twenty-four  hours  should  be  used. 

As  regards  the  quantity  of  urine  daily  voided,  the  mean  average  of 
healthy  persons  is  1500  cubic  centimetres  (fifty  fluidounces).  In  sum- 
mer, when  the  skin  is  acting  freely,  less  fluid  passes  off  by  the  kidneys 
than  in  winter.  The  more  liquid  that  is  taken  into  the  system,  the 
greater  is  the  secretion  of  urine,  unless  the  other  organs  that  eliminate 
water,  as  the  skin,  the  lungs,  and  the  intestines,  are  excreting  with 
unwonted  activity. 

The  quantity  is  diminished  in  all  cases  in  which  the  specific  gravity 
is  increased,  with  the  exception  of  diabetes ;  it  is  diminished  in  acute 

^  Clinical  Lectures  on  Diseases  of  the  Urinary  Organs. 


634  MEDICAL  DIAGNOSIS. 

diseases,  in  fevers,  in  cholera,  and  in  the  early  stages  of  dropsies  ;  in 
some  forms  of  Bright's  disease,  particularly  the  acute  forms,  through 
their  entire  course,  and  often  in  the  last  stage  of  all  forms  of  that 
disease.  It  is,  on  the  other  hand,  augmented  in  cardiac  hypertro- 
phy and  whenever  the  specific  gravity  is  diminished ;  in  hysteria ;  in 
contracted  kidney,  and  in  polyuria.  In  almost  all  vesical  and  renal 
affections  frec{uent  micturition  is  a  marked  symptom, — not  ahvays, 
however,  associated  with  increased  quantity  of  urine. 

The  ingredients  of  urine  are  numerous.  The  principal  are :  urea, 
sulphates,  phosphates,  chlorides,  uric  acid  and  urates,  kreatinin,  hip- 
puric  acid,  mucus,  coloring-matter,  and  a  large  proportion  of  water. 

The  following  data  for  average  normal  urine  are  taken  from  an 
article  by  Charles  Piatt ;  ^  the  ingrechents  are  given  according  to  a 
strictly  scientific  system. 

Reaction,  acidity  in  twenty-four  hours  equivalent  to  2-4  grammes 
of  oxalic  acid.  Total  quantity  of  liquid  in  twenty-four  hours  :  man, 
1450  cc. ;  woman,  1250  cc. 

Grammes  excreted  in  tAventj'-four  hours. 
Man.  Woman. 

Total  solids 60.0  51.0 

Urea 34.0  30.0 

Uric  acid 0.6  0.5 

Kreatinin 0.9  0.8 

Hippuric  acid 0.7  0.6 

Xanthin  and  analogues 0.005 

Minor  organic  matters  including  pigment 0.3 

Sulphur  dioxide  derivable  from  ethereal  sulphates  0.250 

Chlorin    7.3  6.0 

Phosphoric  anhydride 3.0  2.5 

Sulphuric  anhydride 2.2  1.9 

Potassium  oxide    3.0  2.8 

Sodium  oxide 4.5  4.0 

Calcium  oxide 0.3  0.28 

Magnesium  oxide 0.4  0.35 

Ammonia  (NH3) 0.7  0.6 

Iron 0.007 

Besides  the  elements  mentioned,  the  quantities  of  which  fluctuate 
with  the  food-supply  and  with  the  activity  of  tissue-metamorphosis, 
we  meet,  in  morbid  states,  with  substances  that  do  not  exist  at  all  in 
healthy  urine,  or  the  presence  of  which  is  doubtful,  such  as  various 
forms  of  albumin,  sugar,  blood,  bile,  fats,  oxalate  of  lime,  and  certain 
pigments.     Most  of  these  are  dissolved  in  the  urine,  and  are  not  to  be 

1  Journ.  Amer.  Chem.  Soc,  1897,  p.  382. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY   ORGANS.     635 

detected  except  by  delicate  tests  ;  others  form  in  sediments  after  the 
urine  has  been  discharged,  and  may  be  recognized  by  the  microscope. 

As  matters  of  cKnical  interest  we  endeavor  to  fix  tliese  waymarks  : 
the  color,  the  specific  gravity,  the  quantity,  the  reaction,  the  presence 
or  absence  of  such  important  abnormal  ingredients  as  albumin  and 
sugar,  and  the  character  of  the  deposits.  Frequently,  too,  we  extend 
our  examination  until  we  have  determined  approximately,  if  not  accu- 
rately, the  increase  or  diminution  of  the  main  constituents  of  the  urine, 
especially  of  the  urea,  uric  acids,  chlorides,  phosphates,  and  sulphates^ 
and  the  distribution  or  non-distribution  of  bile  and  other  unusual  con- 
stituents through  the  fluid. 

Color. — The  color  of  the  urine  is  much  affected  by  food  and 
medicine,  as  well  as  by  various  morbid  processes,  A  smoky  or  a  red 
aspect  is  apt  to  be  owing  to  admixture  of  blood ;  a  very  light  color 
denotes  generally  an  increase  of  water,  and  is  commonly  found  in 
diabetes,  in  hysteria,  and  in  kindred  nervous  affections.  In  febrile 
diseases  the  urine  is  of  dark  hue.  A  greenish-yellow  or  brownish  tint 
of  the  discharge  is  indicative  of  bile  ;  but  a  similar  tinge  may  be  present 
when  rhubarb  has  been  taken.  A  dirty-blue  urine  happens  from  an 
indigo  sediment,  and  is  alkaline.  Strong  coffee  darkens  the  urine  ; 
turpentine  darkens  and  imparts  a  violet  color  to  it ;  carbolic  acid,  tar, 
and  creosote  render  it  black ;  so  do  disintegrated  blood  and  melanotic 
cancer.  Santonin,  logwood,  and  senna  discolor  it.  The  first-named 
substance  gives  it  a  bright  yellow  color,  which  on  the  addition  of  an 
alkali  becomes  crimson.  Senna  may  impart  to  it  a  brownish  or  a 
deep  red  color,  which,  however,  like  that  due  to  rhubarb,  is  lightened 
on  the  addition  of  mineral  acids,  and  is  thus  distinguished  from  the 
hue  of  urine  containing  blood.  The  altered  appearance  is  mostly  due 
to  the  coloring-matter  of  these  articles  being  excreted  with  urine.    ' 

The  chemistry  of  the  coloring-matters  of  the  urine  is  still  incom- 
plete, and  the  clinical  significance  of  the  color-changes  still  obscure. 
The  principal  normal  coloring-matter  is  urobilin^  which  is  an  oxida- 
tion-product from  blood  and  bile-pigment.  In  febrile  conditions  a 
less  oxidized  product  is  excreted,  which  MacMunn  has  named  patho- 
logical urobilin  and  declares  to  be  identical  with  the  coloring-matter  of 
the  faeces,  stercobilin.  He  further  states  that  the  presence  of  this 
body  in  the  urine  is  to  a  certain  extent  an  indication  of  the  absorp- 
tion of  fecal  matter  and  ptomaines  which  have  not  been  destroyed 
by  the  liver.  Other  pigments  have  been  described,  among  which 
may  be  named  uroerythrin,  urochrome,  and  haematin  free  from  iron, 
hcematojwrphyrin^  and  melanin^  which  occurs  especially  in  the  urine 
in  melanotic  cancer  and  wasting  diseases.     The  employment  of  the 


^36  MEDICAL  DIAGNOSIS. 

spectroscope  is  one  of  the  means  of  distinguishing  between  these 
colors,  but  a  description  of  their  minute  differences  would  be  beyond 
the  scope  of  this  work. 

Specific  Gravity. — We  take  the  specific  gravity  of  urine  to  judge 
of  the  solid  matter  it  contains.  The  readiest  means  is  the  urinometer. 
For  the  implement  to  yield  trustworthy  results  the  fluid  should  be 
brought  to  the  temperature  at  which  the  urinometer  has  been  gradu- 
ated. A  difference  of  seven  degrees  F.  corresponds  to  about  one 
degree  of  the  urinometer.  Most  instruments  are  graduated  for  use 
at  60°  F. ;  the  cheaper  forms  are  often  inaccurate.  Squibb  makes  a 
urinometer  adapted  for  use  at  77°  F.  (25°  C),  which  is  convenient  for 
office  work.  More  accurate  than  the  urinometer  is  the  specific  gravity 
bottle,  or  the  Westphal  balance. 

If  there  be  but  a  small  quantity  of  urine  for  examination,  we  note 
the  amount  and  how  many  volumes  of  distilled  water  it  takes  to  fill 
the  vessel  to  the  height  required  to  float  the  urinometer.  We  then 
multiply  the  number  above  1000  that  the  instrument  shows,  by  the 
total  number  of  volumes  of  the  mixed  fluid.  This  is  only  approxi- 
mate. 

From  the  specific  gravity  we  may  calculate  approximately  the 
quantity  of  solid  matter  passed  by  multiplying  the  number  above  1000 
by  2.33.  This  may  be  done  whether  we  estimate  in  grammes  or  in 
grains.  For  instance,  in  urine  of  specific  gravity  of  1010  there  will 
be  23.3  grammes  of  solid  matter  in  each  1000  grammes  of  urine ;  in 
urine  of  1030,  69.9  grammes.  This  information  obtained,  it  is  easy  to 
find  the  whole  amount  of  solids  contained  in  the  urine  of  twenty-four 
hours,  after  ascertaining  the  quantity  passed  in  that  time.  To  take  the 
first  illustration :  if  1000  grains  yield  23.3  grains  of  solid  matter,  how 
muth  would  be  yielded  by  20,000  (the  quantity  passed,  let  us  say,  in 
twenty-four  hours)  ? 

1000  :  23.3  :  :  20,000  :  x.     x  =  466  grains. 

This  method  is  not  very  precise  ;  when  exactness  is  required,  the 
urine  must  be  evaporated  until  a  dry  residue  is  left,  which  should  then 
be  carefully  weighed. 

The  amount  of  solids  in  healthy  urine  is  variously  estimated.  The 
table  above  given  exhibits  a  fair  average.  As  a  rule,  the  proportion  is 
greatest  in  persons  of  heavy  weight ;  if,  therefore,  we  wish  to  make 
nice  comparisons,  the  weight  of  the  body  should  be  always  stated. 
To  ascertain  how  much  of  the  solid  matter  consists  of  mineral  matters, 
the  organic  substances  must  be  burned  off  at  a  red  heat. 

In  disease,  the  solids,  and  with  them  of  course  the  specific  gravity. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     637 

fluctuate  very  much.  We  find  the  specific  gravity  decidedly  increased, 
rising  to  1030  or  higher,  when  sugar  or  an  excess  of  urea  is  present, 
and  when  the  urine  is  concentrated  and  of  deep  color.  A  low  specific 
gravity  is  met  with  in  chronic  interstitial  nephritis,  in  many  cases  of 
hysteria,  and  in  pale  urine  except  that  of  diabetes.  But  to  be  accu- 
rate— and,  indeed,  accuracy  in  regard  to  the  other  physical  and  chemi- 
cal properties  is  unattainable  without  attending  to  the  same  rule — we 
must  not  lay  stress  on  the  specific  gravity  without  taking  into  account 
the  measure  of  urine  passed  in  the  twenty-four  hours. 

Reaction. — Normal  urine  is  acid.  The  acidity  depends  upon  acid 
salts,  especially  acid  sodium  phosphate.  The  degree  of  acidity  is  not 
always  equal,  and  is  much  influenced  by  digestion.  If  no  food  have 
been  taken  for  hours,  the  discharge  is  highly  acid ;  that  passed  after  a 
meal,  and  while  the  process  of  digestion  is  going  on,  is  but  faintly  so, 
or  even  alkaline.  In  about  three  or  four  hours  after  meals  the  alka- 
line tide  turns,  and  the  acidity  of  the  urine  slowly  increases  until  food 
is  again  taken.  There  seems,  however,  to  be  a  limit  to  the  increase, 
for  Bence  Jones  found  that  continuing  to  fast  for  twelve  hours  beyond 
the  usual  meal-time  did  not  intensify  the  acidity  of  the  urine.  The 
alkalinity  of  the  urine  after  meals  is  rarely  detected  at  the  bedside. 
For,  although  the  urine  may  be  alkaline  when  secreted,  it  is  gener- 
ally mixed  in  the  bladder  with  that  which  collected  before  or  after  the 
alkaline  tide,  and  the  mixed  urine  when  passed  may  have  an  acid 
reaction.  The  acidity  of  the  urine  is  augmented  by  the  administration 
of  the  vegetable  or  the  mineral  acids  ;  yet  they  do  not  cause,  even  in 
large  doses,  as  great  variations  as  does  digestion.  We  find  the  urine 
very  acid  during  a  meat  diet ;  the  acidity  is  also  strongly  marked  if 
any  acid  be  present  in  the  urine  which  sets  the  uric  acid  free,  or  if 
this  be  in  decided  excess. 

For  determining  reaction,  litmus-paper  is  used.  Solution  of  litmus 
is  divided  into  two  parts ;  to  one  part  nitric  acid  is  added,  drop  by 
drop,  until  the  color  is  wine-red.  This  is  then  mixed  with  the  other 
half.  Slips  of  filtering-paper  are  dipped  in  this  and  dried.  They 
have  a  purple  tint,  and  are  very  delicate,  responding  to  a  trace  either 
of  free  acid  or  of  alkali.  We  thus  avoid  the  use  of  two  colors. 
Where  litmus-paper  of  two  colors  is  used,  we  find  that  the  blue  is 
turned  red  by  an  acid ;  the  red,  turned  blue  by  an  alkali.  Litmus- 
paper  is  best  kept  in  a  closed  dark  bottle. 

We  may  estimate  the  amount  of  free  acid  in  the  urine  by  a  solu- 
tion of  sodium  hydroxide  (caustic  soda)  containing  4.0  grammes  to  the 
litre.  This  solution  is  added  drop  by  drop  to  100  cc.  of  urine,  which 
has  been  measured  off  in  a  beaker  glass.     After  the  addition  of  each 

40 


638  MEDICAL  DIAGNOSIS. 

half  cubic  centimetre,  a  drop  of  the  mixture  is  placed,  by  means  of 
a  glass  rod,  on  well-prepared  litmus-paper.  AVhen  the  paper  is  no 
longer  reddened,  the  analysis  is  finished  ;  and  by  noting  how  much  of 
the  standard  solution  has  been  used,  we  can  determine  the  acidity  of 
the  urme,  which  it  is  customary  to  express  as  equal  to  so  many  grains 
of  oxalic  acid,  the  Talue  of  the  sodium  hydroxide  solution  in  terms  of 
oxalic  acid  having  been  previously  ascertained. 

Urine,  when  voided,  remains  ordinarily  acid  for  at  least  a  day ;  but 
it  may  lose  its  acidity  much  sooner.  This  is  always  a  significant  fact, 
having  much  the  same  meaning  as  if  the  fluid  had  been  discharged  in 
a  neutral  or  an  alkaline  state. 

Now,  an  alkaline  reaction  may  result  from  several  causes :  from 
the  effect-  of  digestion,  as  already  mentioned ;  from  the  presence  of 
sodium  or  potassium  carbonate  ;  or  from  the  decomposition  of  the 
urea  into  ammonium  carbonate.  In  the  former  case,  heat  does  not 
restore  the  color  of  the  red  litmus-paper, — it  remains  blue  ;  in  the 
latter,  a  gentle  heat  soon  brings  back  the  original  red  tint.  ^Moreover, 
in  either  case,  the  earthy  phosphates  are  precipitated,  the  fixed  carbo- 
nate causing  the  precipitation  of  the  amorphous  calcium  phosphate ; 
while,  by  the  ammonium  carbonate,  ammonimn  and  magnesium  phos- 
phates, in  conjunction  with  the  calcium  phosphate,  are  thrown  down, 
and  the  triple  phosphate  is  abundantly  formed,  and  can  be  easily 
recognized  under  the  microscope  by  its  prismatic  crj^stals. 

Alkalinity  of  the  urine  from  fixed  alkali  is  not  mconsistent  with 
health.  We  have  adverted  to  the  effects  of  digestion  and  to  the  fact 
that  alkaline  urine  results  from  the  use  of  certain  articles  of  vegetable 
food,  or  of  the  salts  of  sodium  and  potassium.  Urine  owing  its  alka- 
linity to  ammonium  carbonate  is  always  to  be  viewed  as  pathological. 
The  disturbance  is  generally  long  continued,  and  the  urine  loses  its 
acidity  in  the  bladder,  in  consequence  of  a  disease  of  the  mucous  coat 
of  the  viscus,  or  from  being  long  retained  there,  as  in  cases  of  para- 
plegia, or  from  admixture  with  pus,  which  acts  as  a  kind  of  ferment 
and  leads  to  decomposition  of  the  urea. 

Changes  in  the  Quantity  of  the  more  Important  Con- 
stituents of  Urine. —  Urea. — The  amount  of  urea  excreted  by  well- 
nourished,  healthy,  adult  males  in  the  twenty-four  hours  is  estimated, 
in  round  numbers,  by  Roberts  at  Sh  grains  per  pound  weight  of  the 
body,  and  by  Neubauer  and  Vogel  at  25  to  40  grammes,  or  0.37  to  0.6 
gramme  for  every  kilogramme  of  weight  of  the  body.  Purdy  places 
the  mean  excretion  of  urea  in  healthy  adult  males  between  the  ages 
of  twenty  and  forty  years  at  33.18  grammes  (512.1  grains)  in  twenty- 
four  hours.     These  figures  are  like  those  given  by  Piatt. 


THE  URINE,  AND  DISEASES  OF  THE   URINARY  ORGANS.     639 

Urea  is  the  principal  product  of  the  transformation  of  nitrogenized 
substances.  Its  proportion  fluctuates,  therefore,  with  the  variations 
in  the  nature  and  quahty  of  food  partaken  of,  as  well  as  with  the  ac- 
tivity of  the  transformation  of  the  structures  of  the  system :  hence  it 
becomes  the  most  important  index  of  the  waste  and  repair  of  tissues. 
Exertion  of  body  and  of  mind  leads  to  the  discharge  of  a  larger  quan- 
tity of  urea.  If  this  be  replaced  by  a  nourishing  diet,  nothing  is  lost ; 
the  body  retains  its  health.  But  when  the  requisite  amount  of  nitro- 
genized aliment  is  not  taken,  or,  if  taken,  cannot  be  assimilated,  owing 
to  a  disturbance  in  digestion,  the  person  wastes.  We  notice,  too,  in 
acute  febrile  states,  until  their  height  is  reached,  hand  in  hand  with 
the  emaciation  an  increase  of  this  significant  urinary  constituent, — a 
proof,  then,  of  the  rapid  and  unsupplied  disintegration  of  the  tissues. 
We  see  the  same  increase  during  paroxysms  of  intermittent  fever,  m 
inflammations,  and  in  some  cases  of  nervousness ;  also  from  a  pre- 
dominant animal  diet,  and  in  certain  forms  of  mdigestion,  in  which 
the  food  is  speedily  passed  off  in  the  shape  of  urea  instead  of  acting 
its  part  in  the  nutrition  of  the  economy.  Degenerative  changes  in  the 
liver  may  be  accompanied  by  a  diminution  of  urea-excretion. 

A  lessened  quantity  of  urea  is  excreted  during  fasting,  while  on  a 
vegetable  diet,  in  dropsies,  and  in  many  long-continued  organic  dis- 
eases that  gradually  undermine  the  general  nutrition  and  diminish 
tissue-change,  or  in  states  attended  with  diminished  oxidation.  But 
the  decreased  amount  in  the  urine  may  also  be  due  to  a  want  of 
secreting  power  of  the  kidneys.  The  urea,  or  the  products  of  its 
decomposition,  then  act  as  a  poison  in  the  blood ;  and  the  symptoms 
indicative  of  urgemic  poisoning  are  encountered.  Urea  is  sometimes 
not  found  in  the  urine  at  all,  or  only  in  traces,  having  been  replaced 
by  leucine  and  tyrosine. 

Quantitative  estimations  of  urea  are  almost  exclusively  made  by 
the  use  of  solutions  of  sodium  hypochlorite  or  hypobromite,  which 
decomposes  the  urea,  liberating  nitrogen  and  carbon  dioxide  in 
amounts  proportional  to  the  urea  present.  The  carbon  dioxide  is 
kept  in  solution  by  using  excess  of  sodium  hydroxide  or  carbonate, 
and  the  volume  of  nitrogen  is  measured.  The  most  accurate  results 
seem  to  be  obtained  with  the  hypobromite,  but  this  does  not  keep 
well,  and  its  extemporaneous  preparation  is  troublesome  and  annoy- 
ing. Sodium  hypochlorite  is  readily  obtained,  being  the  common 
Labarraque's  solution.  It  keeps  in  good  condition  for  a  long  while, 
and  gives  good  results.  It  must  contain  a  marked  excess  of  sodium 
carbonate.  Several  observers  have  reported  that  improved  effect  is 
obtained  from  the  addition  of  potassium  bromide  (1  gramme  to  25  cc. 


640 


MEDICAL  DIAGNOSIS. 


of  liquor  sodce  chloratce).  To  avoid  the  annoyance  of  using  pure  bro- 
mine, when  hypobromite  solution  is  employed,  Charles  Rice  suggested 
the  use  of  a  solution  of  bromine  in  potassium  bromide.  This  keeps 
Avell,  and  is  more  convenient  to  handle.  In  this  method  the  solutions 
used  are  as  follows :  (a)  10  grammes  of  potassium  bromide  are  dis- 
solved in  80  cc.  iof  water,  10  grammes  of  bromine  added,  and  the 
liquid  shaken  until  the  latter  is  dissolved ;  (6)  10  grammes  of  sodium 
hydroxide  are  dissolved  in  25  cc.  of  water.  For  use,  equal  quantities 
of  the  two  liquids  are  mixed  and  slightly  diluted  with  water.  Sodium 
hypobromite  may  also  be  prepared  by  adding  directly  1  cc.  of  bromine 
to  25  cc.  of  the  above  solution  of  sodium  hydroxide  ;  but  the  liquid 


Fig.  56. 


Fig.  57. 


Doremus's  ureometer. 


Greene's  ureometer. 


must  be  used  within  a  few  hours,  or  accurate  results  cannot  be 
expected.  The  mixture  must  be  made  in  a  well-ventilated  place,  as 
bromine  is  exceedingly  irritating  and  corrosive. 

For  collecting  and  measuring  the  nitrogen  evolved,  many  kinds  of 
apparatus  have  been  devised.  That  of  Hilffner  is  a  standard  model,  but 
simpler  and  less  expensive  forms  are  now  usually  employed  in  clinical 
work.  Fig.  56  shows  a  form  devised  by  Doremus,  which  is  much 
used.  The  apparatus  is  filled  with  solution  of  hypobromite  or  hypo- 
chlorite, so  that  when  the  graduated  tube  is  upright  the  bulb  is  about 
half  filled.  A  large  watch-glass  or  shallow  dish  should  be  placed 
beneath  to  catch  any  overflow.  A  measured  quantity  of  the  urine 
(1  cc.)  is  introduced  by  means  of  the  dropping-tube,  the  opening  being 
pushed  well  into  the  bend  of  the  upright  tube,  and  the  apparatus 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     641 

being  tilted  forward  to  prevent  any  escape  of  bubbles  or  urine  into 
the  large  bulb.  After  about  twenty  minutes  the  volume  of  gas  is  read 
off ;  1  cc.  of  nitrogen  may  be  taken  to  represent  .0028  of  urea,  but 
the  tube  is  usually  graduated  so  as  to  read  directly  the  percentage  of 
urea,  a  deflnite  volume  of  the  urine  being  taken  for  each  test.  An 
improved  form  of  Doremus's  ureometer  is  now  obtainable.  Fig.  57 
shows  Greene's  ureometer,  also  a  simple  instrument. 

Fowler's  method  has  been  endorsed  by  several  careful  observers. 
It  depends  on  the  fact  that  the  decomposition  of  urea  greatly  reduces 
the  specific  gravity  of  the  urine.  It  may  be  performed  as  follows. 
The  specific  gravity  of  the  sample  is  carefully  taken,  and  then  25  cc. 
added  in  a  large  beaker  to  175  cc.  of  solution  of  chlorated  soda  (U.S. P. 
1890),  and,  after  mixing  well,  allowed  to  stand  for  a  few  hours,  when 
the  specific  gravity  is  again  taken.  Multiply  the  specific  gravity  of  this 
residual  liquid  by  7,  add  the  specific  gravity  of  the  original  liquid,  and 
divide  the  sum  by  8,  subtract  from  this  quotient  the  specific  gravity  of 
the  residual  mixture,  multiply  the  remainder  by  0.77,  and  the  product 
is  the  percentage  of  urea.  In  case  the  urine  is  of  high  gravity  it  is 
better  to  use  12.5  cc.  diluted  with  an  equal  volume  of  water  and  then 
add  the  175  cc.  of  solution  of  chlorated  soda.  The  result  must  be 
multiplied  by  2. 

C/Hc  Aeid. — Uric  acid,  like  urea,  is  a  product  of  the  metamorphosis 
of  tissue.  It  was  supposed  by  Liebig  that  the  acid  is  an  early  stage 
of  the  transformation  of  urea.  Hofmann  teaches  that  uric  acid  is 
deposited  owing  to  the  decomposition  of  the  urates  by  the  acid 
phosphate  of  sodium.  Under  ordinary  circumstances,  the  deposition 
of  uric  acid  occurs  subsequently  to  the  expulsion  of  the  urine ;  but 
should  the  acid  sodium  phosphate  be  in  excess,  the  uric  acid  may  be 
precipitated  before  the  secretion  is  voided,  and  thus  give  rise  to  gravel 
and  calculi.  This  may  also  happen  through  too  great  concentration 
of  the  urine. 

The  amount  of  uric  acid  passed  in  twenty-four  hours  varies  from 
0.5  to  1.0  gramme.  It  corresponds  in  general  to  the  amount  of  urea 
in  the  proportion  of  1  to  33.  In  normal  urine  the  presence  of  uric 
acid  cannot  be  detected  without  the  addition  of  a  strong  acid,  since  it 
exists  in  the  form  of  soluble  urates,  which  must  be  first  decomposed. 
The  uric  acid  is  gradually  thrown  down  in  small  red  grains. 

The  characteristic  reaction  of  uric  acid  is  furnished  by  the  murexide 
test.  A  few  drops  of  nitric  acid  are  mixed  with  the  suspected  deposit 
in  a  capsule,  and  the  mixture  is  slowly  evaporated  to  dryness,  best  on 
a  water-bath ;  a  drop  of  ammonium  hydroxide  is  then  added,  which 
produces  instantly  a  rich  purple. 


642 


MEDICAL  DIAGNOSIS. 


But  both  uric  acid  and  the  urates  can  be  easily  and  quickly  dis- 
criminated by  the  microscope.  The  crystals  of  uric  acid  are  readily 
discerned,  notwithstanding  that  they  vary  both  in  size  and  in  form. 
Rhombic  plates  with  rounded  angles  are  frequent.  To  obtain  the 
crystals  rapidly,  where  they  are  not  passed  as  uric  acid,  a  portion  of 
the  suspected  deposit  is  dissolved  in  a  drop  of  potassa,  and  the  alka- 
line solution  treated  with  an  excess  of  acetic  acid ;  after  the  lapse  of 
a  few  hours  crystals  of  uric  acid  will  be  formed. 

Fig.  58. 


Crystals  of  uric  acid,  magnified  about  200  diameters.     Most  of  these  forms  are  seen  in  the  urine  of 

acute  rheumatism. 


The  quantitative  estimation  of  uric  acid  is  regarded  by  many  authori- 
ties as  a  very  important  operation,  and  several  methods  have  been 
devised  for  the  purpose.  Most  of  these  are  tedious  and  difficult.  The 
following  modification  of  more  difficult  methods  was  devised  by  Bart- 
ley,^  and  is  satisfactory  for  clinical  work. 

The  solutions  required  are :  Silver  nitrate  solution^  -^^, — that  is, 
containing  3.4  grammes  of  silver  nitrate  in  1000  cc. 

Magnesium  Mixture. — Ten  grammes  crystallized  magnesium  sul- 
phate, 12  grammes  anlmonium  chloride,  and  100  cc.  aqua  ammoniae, 
U.S.P. 

Ammonium  Hydrosulphide.  or  Potassium  Sulphide. — This  solution 
should  be  freshly  made,  and  of  such  strength  that  its  color  is  that  of 
the  urine. 

The  analytic  process  is  as  follows :  When  the  sample  shows  a 
sediment  of  uric  acid  or  urates,  it  should  be  warmed  with  a  few 
drops  of  sodium  hydroxide  to  dissolve  these,  the  liquid  stirred,  and 

^  Medical  Chemistry,  5th  edit.,  p.  641. 


THE   URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     643 

the  excess  of  alkali  neutralized  by  acetic  acid.  In  operating  on  very 
dark  urines  it  is  well  to  dilute  with  an  equal  volume  of  water.  The 
titration  is  performed  in  hot  solution  to  avoid  precipitation  of  the 
xanthin  bases. 

To  50  cc.  of  the  clear  urine  add  5  cc.  of  the  magnesium  mixture 
and  about  10  cc.  of  ammonium  hydroxide  (U.S.P.), — that  is,  enough 
to  give  a  decided  excess.  Heat  the  solution  on  a  water-bath  and  add 
the  silver  nitrate  solution  in  small  amounts  from  a  burette.  Between 
each  addition  remove  a  drop  of  the  warm  liquid  by  means  of  a  dropper 
pipette,  over  the  end  of  which  a  bit  of  absorbent  cotton  has  been 
tightly  wound  to  serve  as  a  filter,  and,  after  removing  this  filter,  bring 
the  drop  in  contact  with  a  drop  of  the  sulphide  solution  lying  on  a 
white  plate.  This  testing  is  continued  until  the  removed  drop  gives  a 
dark  ring  or  cloud  on  contact  with  the  sulphide  solution.  The  number 
of  cubic  centimetres  of  silver  solution  is  then  read  off  and  0.5  cc. 
deducted  to  allow  for  the  amount  of  solution  required  for  a  perceptible 
reaction  in  the  absence  of  uric  acid.  Each  cubic  centimetre  of  silver 
solution  corresponds  to  0.00336  grain  of  uric  acid. 

As  soon  as  the  process  is  complete,  the  precipitate  settles  rapidly, 
and  it  is  well  to  draw  off  some  of  the  clear  liquid  and  test  again ;  or  a 
drop  of  the  silver  solution  may  be  added  to  make  sure  that  no  further 
precipitation  will  occur.  When  the  solution  cools,  however,  addi- 
tional silver  solution  must  be  added  before  the  end-reaction  is  obtained, 
since  the  xanthin  bases  then  react.  By  making  two  titrations,  one 
with  the  hot  liquid  and  one  with  the  cold,  the  excess  of  cubic  centi- 
metres in  favor  of  the  latter,  being  multiplied  by  0.0015,  will  give  the 
amount  of  xanthin  bases. 

In  disease,  the  fluctuations  in  the  quantity  of  uric  acid  are  great ; 
as  a  general  rule,  they  correspond  to  the  rise  and  fall  of  urea.  We 
find  the  acid  diminished  in  hydruria  and  in  affections  in  which  the 
eliminating  power  of  the  kidneys  is  interfered  with,  as  in  the  more 
advanced  stages  of  Bright's  disease  and  in  antemia  and  chlorosis.  An 
increase  is  encountered  in  acute  inflammations,  in  fevers,  in  functional 
disorders  and  many  of  the  structural  affections  of  the  liver,  in  heart 
and  lung  diseases  attended  with  dyspnoea,  in  leukaemia,  and  in  acute 
rheumatism. 

We  must,  however,  be  careful  not  to  suppose  the  uric  acid  to  be  in 
excess  because  it  is  readily  precipitated.  It  may  or  may  not  be  in 
larger  amount :  the  sediment  merely  proves  an  augmentation  of 
acidity  in  the  urine  sufficient  to  take  away  the  base  from  the  uric  acid. 
This  happens  often  as  the  result  of  acid  fermentation  of  the  urine. 
Frequently  urates  are  separated  along  with  the  uric  acid ;   we  find 


644  MEDICAL  DIAGNOSIS. 

then  generally  a  dark  urine  of  high  specific  gravity  and  of  verj^  acid 
reaction. 

Persons  who  habitually  pass  urine  of  the  character  described  are 
subject  to  gastric  or  hepatic  disorders.  They  are  also  often  gouty,  or 
lithEemic,  and  frequently  consumers  of  a  large  amount  of  anmial  food, 
or  intemperate  or  mdolent  in  their  habits. 

Uric  acid  or  urates  are  never  found  as  sediments  in  freshly  voided 
healthy  urine.  Occasionally  precipitates  of  uric  acid  or  urates  occur 
in  the  urinary  passages.  Now,  these  sediments  may  concrete  and 
form  the  nuclei  of  calculi ;  or  they  may  be  passed  in  small  particles 
commonly  spoken  of  as  "  gTavel." 

Urates. — The  pathological  conditions  m  which  the  urates  are 
changed  are  much  the  same  as  those  in  which  alterations  in  uric  acid 

Fig.  59. 


Mixed  mates. 


occur.  The  urates  are  principally  the  sodium,  potassium,  and  ammo- 
nium urates.  The  deposits  formed  by  their  precipitation  are  of  pink 
color,  sometimes  brown,  or  like  brick-dust,  or  yelio^^ish,  or  even 
white.  From  pale  urine  of  low  specific  gravity  a  white  sediment  is 
apt  to  settle.  All  the  deposits  are  dissolved  with  readiness  by  heat. 
Acids  decompose  them  and  separate  uric  acid.  They  are  all  more 
soluble  in  warm  water  than  in  cold,  and  the  neutral  salts  are  more 
soluble  than  the  acid  ones. 

Under  the  microscope,  the  urates  are  seen  to  be  either  irregular, 
amorphous  particles,  needle-like  crystals,  dumb-bells,  or  round  glob- 
ules of  various  sizes,  from  some  of  wliich  fine  needles  project.  The 
latter,  like  the  dumb-bells,  are  commonly  supposed  to  be  sodium 
urate ;  the  globules  and  crystals,  sodium  urate  and  ammonium  luate ; 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     645 

the  granular,  amorphous  powder,  mixed  urates,  more  especiaUy  .sodium 
urate  and  potassium  urate.  These  amorplious  urates  may,  under  the 
microscope,  be  mistaken  for  calcium  phosphate.  The  differential  test 
consists  in  their  behavior  with  acids  :  the  phosphate  is  dissolved  by 
acetic  or  hydrochloric  acid;  the  urates  are  gradually  transformed  into 
crystals  of  uric  acid.  Then,  a  deposit  of  calcium  phosphate  is  often 
more  cloudy  than  the  urates,  and,  unlike  them  or  uric  acid,  is  not 
soluble  in  liquor  potassse.  From  calcium  carbonate,  which  also  occurs 
in  a  granular  form,  both  the  urates  and  the  calcium  phosphate  are 
distinguished  by  the  effervescence  of  the  carbonic  acid  which  happens 
on  the  addition  of  a  strong  acid. 

Urme  containing  a  sediment  of  urates  is  generally  markedly  acid, 
or  soon  becomes  so,  either  from  an  absolute  increase  of  the  uric  acid, 
or  in  consequence  of  changes  in  some  of  the  constituents  of  the  fluid 
— as  of  the  pigment — which  take  place  either  before  or  shortly  after 
emission.  Not  infrequently,  too,  it  is  scanty,  and  the  urates  are  de- 
posited as  soon  as  the  urine  cools  to  the  temperature  of  the  atmos- 
phere. Their  precipitation  may  be,  and  indeed  often  is,  due  to  there 
not  being  water  enough  to  hold  them  in  solution.  We  may  judge  of 
this  being  the  case  by  ascertaining  the  amount  of  urine  passed  in 
twenty-four  hours.  If  the  quantity  be  about  normal,  the  deposit  is  in 
all  likelihood  due  to  an  excess  of  urates.  In  cold  weather  these 
deposits  occur  more  quickly  and  more  extensively  than  in  warm. 

Sediments  of  urates  are  at  times  met  with  in  pale  urine,  and  with- 
out either  diminution  of  water  or  excess  of  acidity.  The  urine  yields 
but  a  faintly  acid  or  a  neutral  or  an  alkaline  reaction,  and  under  the 
latter  circumstances  calcium  phosphate,  or  even  triple  phosphates, 
may  be  observed  to  accompany  the  urates.  The  urate  present  is  acid 
ammonium  urate. 

Phosphates. — The  phosphates  are  derived  in  part  from  the  food,  in 
part  from  the  disintegration,  or  rather  the  oxidation,  of  the  dismte- 
grated  albuminous  substances,  and  especially  of  the  nerve-structures. 
They  occur  either  as  calcium  and  magnesium  phosphates,  the  earthy 
phosphates,  which  exist  in  small  amounts,  about  one  gramme  in  twenty- 
four  hours,  and  as  sodium  phosphate,  about  three  times  as  abundant, 
forming  the  greater  part  of  the  alkaline  phosphates. 

In  health  the  phosphates  are  kept  in  solution  by  their  acidity  ;  but 
as  soon  as  the  urine  ceases  to  be  acid  they  are  deposited.  Hence  the 
appearance  of  phosphates  bespeaks  a  neutral  or  an  alkaline  condition 
of  the  urine,  with  the  exception  that  calcium  phosphate  may  occur  in 
acid  urine.  Often  the  fluid,  as  we  have  already  seen,  becomes  alkaline 
from  the  decomposition  of  the  urea  into  ammonium  carbonate.     This 


646 


MEDICAL  DIAGNOSIS. 


acts  upon  the  phosphate,  forming  ammonio-magnesium  phosphates, 
which  crystalHze  commonly  in  transparent  prisms  or  in  feathery-look- 
ing bodies,  easily  distinguished  from  the  amorphous  powder  or  small 
round  globules  of  calcium  phosphate.  Yet  there  is,  as  Roberts  has 
pointed  out,  a  crystalline  form  of  calcium  phosphate  which  might  be 
mistaken  for  one  of  the  stellar  forms  of  uric  acid,  but  it  may  be  dis- 
tinguished by  its  being  invariably  colorless.  These  earthy  phosphates 
are  all  readily  soluble  in  acids,  even  in  weak  acids  like  acetic  acid,  and 
this  at  once  distinguishes  them,  even  under  the  microscope,  from  cal- 
cium oxalate,  which  some  forms  resemble.  In  many  specimens  of 
urine  they  are  precipitated  by  heat ;  but  the  addition  of  an  acid  soon 
dissolves  them,  and  thus  prevents  the  turbidity  from  being  mistaken 
for  that  due  to  albumin. 

Fig.  60. 


Earthy  phosphates ;  the  granules  are  chiefly  calcium  phosphate,  the  rest  triple  phosphates. 


The  triple  phosphates  are  often  met  with  in  heavy  deposits  mixed 
with  pus,  especially  in  the  alkaline  purulent  urine  resulting  from 
chronic  vesical  catarrh.  They  are  also  seen  in  cases  of  retention  of 
urine  due  to  temporary  or  permanent  paralysis  of  the  bladder,  as  in 
low  fevers,  in  hemiplegia,  or  in  paraplegia.  They  are  found,  too,  in 
many  affections  in  which  the  vital  powers  have  been  seriously  lowered 
and  the  acidity  of  the  urine  diminished,  as  during  convalescence  from 
acute  disease.  Under  the  latter  circumstances,  and  in  fact  whenever 
the  urine  has  become  alkaline  from  the  presence  of  a  fixed  alkali,  the 
phosphatic  deposit  shows  a  large  excess  of  the  amorphous  phosphates, 
if,  indeed,  it  do  not  altogether  consist  of  them. 

Urine  alkaline  from  fixed  alkali,  and  depositing  phosphates,  is,  un- 
less this  condition  have  been  brought  about  temporarily  by  fruit  or 
other  food,  a  matter  of  serious  import.     We  encounter  it  in  persons 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     647 

laboring  under  great  general  debility  and  indigestion  associated  with 
an  impaired  tone  of  the  nervous  system,  and  with  aching  pains  in  the 
lumbar  region  and  a  tendency  to  boils, — in  fact,  in  those  of  whom  it 
is  customary  to  speak  as  exhibiting  the  phosphatic  diathesis,  or  as 
having  phosphaturia.  Such  a  morbid  state  is  not  uncommon  in  men 
depressed  by  mental  toil  or  anxiety,  and  may  become  associated  with 
harsh,  dry  skin,  thirst,  enormous  flow  of  urine  and  marked  emaciation, 
giving  rise  to  so-caWed  phosphatie  diabetes.  The  excretion  of  phosphates 
may  be  from  seven  to  nine  grammes  daily ;  the  urine  is  usually  acid. 
In  some  cases  there  is  also  sugar,  or  this  makes  its  appearance  subse- 
quently. 

In  spite  of  the  distinct  sediment  of  the  phosphates,  it  is  sometimes 
doubtful  if  the  latter  are  really  increased  in  quantity.  The  want  of 
the  acidity  of  the  urine  permits  their  precipitation,  and  causes  them 
to  become  readily  apparent.  On  the  other  hand,  the  phosphates  may 
be  actually  in  excess,  and  yet  this  excess  be  concealed  from  view. 
This  happens  especially  with  the  alkaline  phosphates,  the  proportions 
of  which  change  in  disease  much  more  than  do  the  earthy  phosphates, 
and  indicate  much  more  clearly  the  variations  of  the  phosphoric  acid. 

Now,  a  real,  not  merely  an  apparent,  increase  of  the  phosphates 
occurs,  according  to  Bence  Jones,  in  acute  inflammatory  diseases  of  the 
nervous  structure,  and  in  fractures  of  the  skull  when  an  inflammatory 
action  takes  place  in  the  brain.  It  also  occurs  after  mental  strain.  We 
find  the  phosphates  also  augmented  by  the  abundant  use  of  animal 
food,  and  by  very  active  exercise.  The  earthy  phosphates  are  mark- 
edly increased  in  rickets  and  in  extensive  bone-disease ;  the  phos- 
phoric acid,  as  well  as  the  sulphuric  acid,  the  urea,  and  the  sodium 
chloride,  is  excreted  in  less  amount  than  in  health  during  the  course 
of  a  maniacal  paroxysm,  in  epilepsy,  and  in  melancholia.  In  gout  as 
well  as  in  Bright's  disease,  too,  the  excretion  of  phosphoric  acid  is 
diminished. 

To  determine  the  proportion  of  the  earthy  phosphates,  a  few  drops 
of  ammonia  are  added  to  the  urine ;  soon  a  whitish  precipitate  is 
produced,  which  is  not  removed  by  heat.  From  the  quantity  of  the 
deposit,  after  settling,  we  may  form  a  rough  estimate  of  that  of  the 
earthy  phosphates.  In  an  ordinary-sized  test-tube  a  deposit  one 
centimetre  high  represents  a  normal  amount.  But  to  ascertain  the 
amount  accurately  we  must  employ  a  graduated  glass,  separate  the 
precipitated  phosphates  by  filtration,  ignite  them  in  a  platinum  cap- 
sule, and  weigh  the  ash.  The  alkaline  phosphates  are  not  thrown 
down  by  alkalies,  and,  unlike  the  earthy  phosphates,  are  very  soluble 
in  water.      They  are  procured   by  taking. the  fluid  from  which  the 


648  MEDICAL  DIAGNOSIS. 

earthy  phosphates  have  been  carefuhy  removed  by  filtration,  and 
adding  to  it  a  saturated  solution  of  magnesium  sulphate.  Or  we  add 
to  the  urine  about  one-third  as  much  of  the  magnesium  mixture,  and 
if  the  precipitate  be  copious,  giving  the  fluid  the  appearance  of  cream, 
the  alkaline  phosphates  are  in  excess  ;  if  there  be  merely  a  milky 
turbidity,  they  are  normal. 

From  the  deposit  obtained  in  testing  for  the  phosphates,  some  idea 
may  also  be  formed  of  the  quantity  of  phosphoric  acid  in  the  urine. 
The  average  quantity  passed  by  an  adult  male  in  twenty-four  hours  is, 
according  to  Vogel,  about  3.5  grammes,  or  about  54  grains.  For  the 
volumetric  processes  by  which  the  amount  of  the  acid  may  be  deter- 
mined, I  refer  to  special  treatises  on  the  chemistry  of  the  urine. 

Chlorides. — The  chlorides  in  the  urine  are  derived  from  the  food  ; 
they  correspond  closely  with  the  amount  of  salt  ingested.  In  conse- 
quence, the  sodium  chloride — the  main  chloride  in  the  urine,  for  it 
contains  but  little  potassium  chloride  and  calcium  chloride — is,  even  in 
health,  liable  to  great  fluctuations  ;  the  mean  in  twenty-four  hours  is 
estimated  by  Vogel  and  Parkes  at  11.5  grammes,  or  about  177  grains. 
Bischoff  states  the  average  at  14.73  grammes.  Large  quantities  of 
chlorides  are  excreted  after  active  bodily  or  mental  exercise,  smaller 
quantities  when  the  body  is  at  rest,  as  at  night.  In  disease,  very 
various  amounts  are  eliminated  with  the  urine.  In  cases  of  chronic 
indigestion,  of  dropsy,  and  during  an  ague-fit,  the  chlorides  are  dimin- 
ished. In  typhus  fever  and  in  acute  inflammatory  affections  they  sink 
to  a  low  level,  and  rise  again  in  convalescence :  an  increase  after  a 
diminution  is  thus  always  a  favorable  sign.  We  may  study  these 
changes  in  pleurisy  and  pericarditis,  but  especially  in  pneumonia.  At 
the  period  of  hepatization  the  chlorides  are  absent  from  the  urine,  and 
appear  in  increased  quantity  in  the  sputum ;  during  resolution  they 
reappear  in  the  urine. 

,  Sodium  chloride  is  detected  by  acidulating  the  urine  with  nitric 
acid  and  adding  a  solution  of  silver  nitrate  ;  a  dense  white  precipitate 
of  silver  chloride  quickly  appears,  insoluble  in  nitric  acid,  but  soluble 
in  ammonia.  The  amount  of  the  chloride  is  approximately  estimated 
by  comparison  with  healthy  urine,  or  by  employing  the  method  of 
Hofmann  and  Ultzmann.  According  to  this,  if  in  using  a  solution 
of  silver  nitrate  of  definite  strength,  1  to  8,  we  find  curd-like 
masses  of  silver  chloride  falling  to  the  bottom,  which  on  shaking  the 
glass  do  not  separate,  we  judge  the  chlorides  to  be  in  normal  amount. 
If  the  precipitate  of  silver  chloride  be  small,  yV  P^r  cent,  or  less,  a 
simple  milky  turbidity  arises  and  no  curdy  mass  deposits  ;  whereas  if 
the  chlorides  be  entirely  wanting  there  is  neither  milky  cloud  nor  tur- 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     649 

bidity.  If  the  urine  contain  much  albumin,  this  should  be  coagulated 
and  removed  by  filtering  before  the  test  is  applied. 

Suljyhates. — Sulphates  are  found  in  the  urine  in  large  quantities. 
They  consist  of  potassium  sulphate  and  sodium  sulphate,  the  former 
in  excess.  Like  the  alkaline  phosphates,  they  are  soluble  in  the  urine. 
To  detect  them,  a  few  drops  of  nitric  acid  are  added  to  urine,  and 
subsequently  from  fifteen  to  twenty  drops  of  a  saturated  solution  of 
barium  chloride,  when  a  white  precipitate  insoluble  in  acids  occurs. 
If  there  be  merely  an  opaque  milky  cloudiness,  the  sulphates  are  in 
normal  quantity. 

The  sulphates  are  obtained  in  part  from  the  food,  in  part  from  the 
oxidation  of  the  sulphur  entering  into  the  constitution  of  the  albu- 
minous substances  of  the  body  and  the  subsequent  union  with  a  base 
of  the  sulphuric  acid  which  is  formed.  They  are  enhanced  by  an 
exclusively  animal  diet,  after  violent  exercise,  in  acute  rheumatism,  in 
pneumonia,  and  in  all  acute  febrile  processes  with  large  excretion  of 
urea ;  in  fact,  their  increase  is  apt  to  go  hand  in  hand  with  that  of 
urea.  The  administration  of  potassium  raises  in  a  striking  degree  the 
proportion  of  the  sulphates.  The  sulphates  show  decrease  during  an 
exclusively  vegetable  diet  and  in  urine  of  low  specific  gravity. 

The  average  daily  quantity  of  sulphuric  acid  passed  in  the  urine  is 
about  two  grammes.  Vogel  gives  an  easy  method  of  determining  ap- 
proximately whether  it  is  increased  or  diminished.  After  ascertaining 
the  whole  amount  of  urine  in  twenty-four  hours, — say  it  is  2000  cc, 
and  then  each  100  cc.  would  contain  0.10  gramme  of  sulphuric  acid, 
— 100  cc.  are  rendered  acid,  and  as  much  of  a  test-solution  of  barium 
chloride  ^  is  added  as  corresponds  with  0.05  gramme  of  the  acid.  The 
mixture  is  now  filtered,  and  if  the  filtered  liquid  be  not  made  turbid 
by  the  barium  chloride,  we  may  infer  that  the  patient  has  secreted  less 
than  one  gramme  of  sulphuric  acid  in  the  twenty-four  hours.  If  the 
liquid,  however,  be  rendered  turbid  by  barium  chloride,  a  further 
quantity  of  this  agent,  corresponding  with  0.5  gramme  of  sulphuric 
acid,  is  added ;  and  if  the  filtrate  be  still  rendered  turbid,  it  is  evident 
that  the  quantity  of  sulphuric  acid  is  greater  than  normal.  In  addi- 
tion to  the  sulphates  proper,  the  urine  contains  small  quantities  of 
derivatives  of  sulphuric  acid,  known  as  the  ethereal  sulphates,  one  of 
which  is  phenylsulphuric  acid.  The  origin  of  these  bodies  is  believed 
to  be  in  some  way  connected  with  the  action  of  putrefactive  processes 

^  Made  generally  by  dissolving  30.5  grammes  of  crystallized  barium  chloride, 
powdered  and  air-dried,  and  diluting  the  solution  up  to  1  litre  ;  1  cc.  of  it  then 
■equals  10  milligrammes  of  sulphuric  anhydride. 


650  MEDICAL  DIAGNOSIS. 

dependent  on  micro-organisms,  but  as  yet  no  definite  information  as  to 
their  exact  clinical  significance  is  at  hand. 

Kreatin  and  Kreatinin. — These  substances  found  in  the  urine  are 
purely  excrementitious,  and  are  derived  from  a  disintegration  of  the 
muscular  tissue.  Kreatinin  is  the  product  of  the  change  of  kreatin. 
From  0.5  to  1  gramme  is  excreted  daily. 

But  few  observations  have  as  yet  been  made  on  the  increase  of 
kreatin,  or  on  its  significance  in  showing  the  activity  of  nutrition  in 
the  muscles  in  health  or  in  disease.  Active  muscular  exercise  aug- 
ments the  quantity ;  and  the  same  effect  is  probably  produced  by  all 
spasmodic  affections,  and,  as  Munk  has  shown,  at  the  height  of  acute 
disease,  while  kreatin  is  diminished  during  convalescence,  and  in 
advanced  degeneration  of  the  kidneys. 

Both  kreatin  and  kreatinin  are  generally  included,  in  analyses, 
under  the  head  of  nitrogenous  bodies.  Under  the  microscope  the 
crystals  of  kreatin  are  colorless  and  transparent. 

Presence  of  Abnormal  Substances  in  the  Urine. — Here 
may  be  mentioned  the  ingredients,  such  as  bile  and  blood,  observed  in 
the  urine  in  disease  only ;  and  along  with  them  I  shall  notice  those 
constituents  the  occurrence  of  which  in  healthy  urine  is  occasional, 
but  of  which  it  is  certain  that  their  presence  in  any  marked  degree  is 
abnormal. 

Oxalate  of  Lime^  Calcium  Oxalate. — There  can  be  no  doubt  that 
the  crystals  are  not  found  in  large  numbers  except  in  a  morbid  con- 
dition. Some  pass  habitually  a  considerable  quantity.  They  ar& 
generally  persons  weighed  down  by  care  and  anxiety,  or  who  over- 
task their  brains  by  incessant  application  to  study,  or  weaken  their 
nervous  power  by  excessive  sexual  indulgence  or  by  masturbation. 
Sometimes  they  are  troubled  with  frequent  seminal  emissions  and 
irritation  of  the  bladder,  or  they  are  dyspeptic,  and  suffer  from  un- 
easiness after  meals ;  but  the  appetite  may  be  good  and  the  digestion 
unimpaired.  They  are  always  languid,  and  either  very  irritable  or 
very  dejected.  Frequently  they  complain  of  loss  of  memory,  and  of 
a  sensation  of  weight  or  of  a  dull  pain  across  the  loins.  They  are 
hable  to  boils  and  carbuncles,  grow  thin,  and  evidently  are  generally 
out  of  health.  The  urine  is  of  high  specific  gravity,  shows  an  increase 
of  urea,  and  ordinarily  a  cloudy  deposit  consisting  of  mucus  and  the 
crystallized  oxalates.  Not  infrequently  traces  of  albumin  are  associated 
with  the  calcium  oxalate. 

This  is  the  disorder  called  oxaluria,  and  is  generally  combined 
with  tissue-changes  and  increased  excretion  of  urea.  Its  existence  as 
a  separate  affection  has  been  denied ;  but  I  beheve  the  clinical  asso- 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     651 

ciation  of  a  considerable  number  of  oxalates  with  the  symptoms 
mentioned  to  be  undoubted.  The  presence  of  uric  acid  and  of  oxalates 
is  not  uncommon  in  lithsemia.  The  origin  of  the  oxalic  acid  is  not 
certain.  It  is  generally  the  product  of  incomplete  oxidation  of  organic 
matters  in  the  body,  as  well  as  of  sugar,  of  starch,  and  of  the  salts  of 
the  vegetable  acids.  Probably  in  the  first  class  of  cases  alone  are  the 
constitutional  symptoms  described  present.  In  the  others  we  may  at 
times  detect  evidence  of  the  irritation  of  a  calculus,  or  of  disease  of 
the  bladder  or  the  kidneys.  Acid  fermentation  of  mucus  in  the 
urinary  passages  also  occasions  it. 

Calcium  oxalate  may  be  detected  in  the  urine  when  articles  which 
contain  it,  such  as  sorrel  and  the  rhubarb  plant,  have  been  eaten,  or 

Fig.  61. 


Calcium  oxalate  crystals. 


after  the  free  use  of  tomatoes  or  of  carbonated  drinks.  It  may  be  also 
found  in  the  urine  of  those  recovering  from  severe  acute  maladies, 
and  is  encountered,  but  only  in  very  small  quantities,  in  the  urine  of 
healthy  persons.  But  in  neither  instance  is  it  permanent,  nor  can  the 
presence  of  a  few  crystals  be  looked  upon  as  of  the  least  importance. 

The  microscope  is  incomparably  the  readiest  means  of  detecting 
the  salt.  This  appears  in  well-defmed  octahedra  of  varying  size,  and 
in  dumb-bell  bodies.  The  former  are  the  more  common  and  charac- 
teristic ;  for  the  dumb-bells  are  not  frequent,  nor  is  this  formation 
peculiar  to  calcium  oxalate.  Occasionally,  long  or  pointed  octahedra 
or  prismatic  crystals  are  observed.  All  forms  are  unaffected  by  acetic 
acid. 

The  oxalates  are  often  mixed  with  deposits  of  urates  or  uric  acid]; 
a  fact  which   some  use  as  an  argument  that  oxalic  acid  is  but  the 


^52  MEDICAL  DIAGNOSIS. 

direct  transformation  of  uric  acid.  Sometimes — Beneke  says  con- 
stantly— the  earthy  phosphates  coexist  in  large  amount  with  the  oxa- 
lates. Occasionally  the  irritation  from  the  passage  of  the  crystals  gives 
rise  to  tube-casts,  A  case  came  under  my  observation  years  since  in 
which  a  patient  suffering  from  a  protracted  attack  of  oxaluria  voided 
for  weeks,  along  with  the  oxalates,  hyaline,  exudative,  or  small  waxy 
casts.  Neither  heat  nor  nitric  acid  detected  albumin.  Under  treatment, 
the  crystals  disappeared  from  the  urine,  and  mth  them  the  casts.  The 
urine  examined  ten  years  afterwards  showed  not  the  slightest  sign  of 
degeneration  of  the  kidneys. 

Leucine  and  Tyrosine. — Both  these  substances  are  the  result  of  the 
decomposition  of  highly  nitrogenous  animal  matter,  are  very  similar, 
and  are  usually  associated.  They  replace  urea,  and  have  been  found 
in  the  urine  only  in  disease,  as  in  acute  yellow  atrophy  of  the  liver,  m 
typhoid  fever,  in  smallpox,  in  phosphorus  poisoning,  in  cancer  of  the 
liver,  and  in  other  forms  of  enlargement  of  the  organ. ^  They  are 
either  spontaneously  deposited,  or  form  a  deposit  if  a  small  quantity 
of  urine  be  evaporated.  Tyrosine  is  readily  detected  by  the  micro- 
scope. It  crystallizes  in  long,  very  fme,  shining  needles,  which  may 
congregate  in  globular  bodies. 

Hofmann  has  proposed  the  follomng  delicate  chemical  test  for 
tyrosine.  A  solution  of  mercuric  nitrate,  nearly  neutral,  is  to  be 
treated  with  the  solution  suspected  to  contain  tyrosine  ;  if  it  be  pres- 
ent, a  reddish  precipitate  is  produced,  and  the  supernatant  fluid  is  of 
a  very  dark  rose-color.  Leucine  crystallizes  in  granular  masses,  con- 
sisting of  roundish  globules,  sometimes  of  concentric  form,  and  for 
the  most  part  of  yellowish  color  and  resembling  oil-drops,  but,  unlike 
oil,  is  not  dissolved  by  ether.  The  chemical  test  for  leucine  is  to  place 
the  suspected  deposit  on  platinum  foil  and  then  to  evaporate  it  with 
nitric  acid.  The  residue  is  moistened  with  caustic  soda,  and  this 
mixture  is  carefully  heated  over  a  spirit-lamp.  It  is  gradually  con- 
densed into  oily-looking  drops, — a  property  which  Scherer  has  pointed 
out  as  a  characteristic  of  leucine. 

Tyrosine  is  the  parent  substance  from  which  the  acid,  homogenti- 
sinic  acid,  is  formed  that  occasions  alcaptonuria.  In  this  rare  disorder 
the  urine  when  passed  rapidly  becomes  of  deep  brown  color  and 
finally  black.  The  fact  that  urine  containing  alcaptone  reduces  Feh- 
ling's  solution,  though  only  with  the  aid  of  heat,  causes  it  to  be  mis- 
taken for  saccharine  urine.     But  both  the  bismuth  test  and  the  fer- 


1  Vaughan  and  Beringer,  Contributions  from  the  Chemical  Laboratory  of  the 
University  of  Michigan,  vol  i.,  1882. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     653 

mentation  test  give  negative  results.  Alkalies  greatly  intensify  the 
brown  color  of  the  urine.  The  disorder  does  not  markedly  affect  the 
general  health,  and  frequently  dates  from  childhood.  It  is  most  com- 
ijjon  in  males. ^ 

Bile. — The  occurrence  of  bile  in  the  urine  imparts  to  it  a  very 
dark  color.  All  the  constituents  of  the  bile  may  appear  in  the  urine, 
or  only  the  pigment,  without  the  acids  or  their  salts.  The  pigment  is 
sometimes  found  transiently,  and  in  small  quantities,  without  yellow- 
ness of  the  skin :  its  more  permanent  and  marked  occurrence  is,  how- 
ever, always  attended  with  jaundice.  It  may  be  discerned  before  the 
discoloration  of  the  skin  is  noticeable,  and  after  it  has  lost  its  yellow  hue. 
The  biliary  acids  are  not  of  necessity  present  in  the  urine  of  icterus. 

The  detection  of  the  coloring-matter  of  bile  is  effected  by  pouring 
a  small  quantity  of  urine  on  a  white  plate ;  a  drop  of  the  yellow 
fuming  nitric  acid  of  commerce  is  then  permitted  to  fall  on  the  thin 
layer  of  fluid.  Soon  a  play  of  color  takes  place,  beginning  with  green 
and  blue,  passing  to  violet  and  red,  and  often  finally  to  yellow  or 
brown ;  the  green  is  the  predominant  and  the  most  characteristic  of 
the  colors.  According  to  Frerichs,^  this  reaction  may  fail  in  cases 
where  the  other  symptoms  of  jaundice  are  undoubted,  owing  to  the 
bile-pigment  having  already  passed  through  stages  of  transformation. 
When  this  is  the  case,  the  urine  is  at  one  time  of  a  brown  or  brown- 
ish-red color,  and  becomes  red  on  the  addition  of  nitric  acid ;  at 
another  time  it  is  of  a  deep  red,  which  is  converted  by  nitric  acid 
into  a  dark  bluish-red.  Murchison  has  made  a  similar  observation  ^  in 
cases  where  jaundice  has  resulted  from  a  blood-poison,  and  he  has 
frequently  found  the  urine  to  present  these  characters  where  there 
has  been  no  jaundice,  yet  obvious  derangement  of  the  liver. 

Heller's  test  is  also  very  easily  performed.  In  a  small  beaker  glass 
containing  about  6  cc.  (1.62  fluidrachms)  of  pure  hydrochloric  acid 
mix  enough  urine  to  discolor  this,  then  allow  nitric  acid  to  trickle  along 
the  sides  and  form  a  layer  underneath.  A  beautiful  play  of  colors  takes 
place  at  the  point  of  contact,  and,  on  stirring  up  the  mixture  with  a 
glass  rod,  throughout  it. 

The  following  is  also  a  delicate  test  for  bile.  Add  to  the  urme 
some  calcium  chloride  solution,  and  then  solution  of  sodium  carbonate. 
The  precipitate  will  contain  any  bile-pigment,  and  may  be  collected 
by  agitating  the  liquid  with  chloroform.      The    chloroform  solution 


1  Garrod,  Med.-Chimr.  Trans.,  1899. 

*  Diseases  of  the  Liver,  Sydenham  Soc.  Transl.,  vol.  i.  p.  100, 
'  CUnical  Lectures  on  Diseases  of  the  Liver. 

41 


654  MEDICAL  DIAGNOSIS. 

should  be  agitated  ^Yith  water  and  acidulated  ^Yith  acetic  acid.  Any 
bilirubin  will  color  the  chloroform  yellow,  which  ^\ill  become  green 
on  adding  the  acid. 

If  the  urine  contain  only  altered  biliar}"  coloring-matters  (bilifuscin), 
they  may,  according  to  Hofmami  and  Ultzmann,  be  recognized  as  fol- 
lows. A  piece  of  clean  white  linen  is  dipped  into  the  urine,  and  then 
allowed  to  dry  ;  it  is  discolored  brown.  Further  confirmation  is  found 
in  a  ver}^  dark  reaction  for  urophgein  (by  adding  about  double  the 
quantity  of  urine  to  strong  sulphuric  acid),  the  urine  appearing  not 
garnet-red.  but  black.  A  similar  reaction  is  produced  only  by  the 
presence  of  sugar  and  of  blood-coloring  matter,  both  of  which  can  be 
excluded  by  the  appropriate  tests. 

The  biliary  acids  are  sought  for  by  Pettenkofer's  test.  It  consists 
in  adding  a  few  drops  of  a  solution  of  sugar  to  a  small  portion  of  urine 
contained  in  a  test-tube  or  in  a  chma  dish,  placed  in  cold  water.  To 
this  mixture  an  excess  of  concentrated  sulphuric  acid  is  added,  drop 
by  drop.  The  fluid  assumes  a  yellowish-red  color,  which,  if  bile  be 
present,  passes  into  a  crimson  or  violet.  But  it  is  inconclusive  ;  for 
urine  containing  an  excess  of  indican  or  oleic  acid  or  albumin  may 
display,  when  thus  treated,  a  reaction  similar  to  that  caused  by  the 
bile  acids.  The  spectrum,  which  shows  lines  by  F  and  near  to  E, 
affords,  according  to  Schunck,  the  most  certain  test  of  bile  acid ;  in- 
deed, minute  distinctions  between  the  different  coloring-matters  can- 
not be  attained  except  through  spectroscopy. 

A  delicate  test  ybtj  generally  used  for  bihary  acids  is  Oliver's  test. 
The  test  solution  consists  of  half  a  drachm  of  pulverized  peptone, 
four  grains  of  salicylic  acid,  half  a  drachm  of  acetic  acid,  and  dis- 
tilled water  to  make  eight  ounces.  The  fluid  is  made  transparent  by 
repeated  filtering.  Twenty  minims  of  urine  are  added  to  sixty  minims 
of  the  test  solution ;  if  bile  acids  are  in  excess,  a  distinct  mUkiness 
quickly  appears. 

Indican. — Among  the  so-called  ethereal  sulphates  occurring  in 
urine,  of  special  significance  is  potassium  indoxyl  sulphate,  indican. 
It  exists  in  mere  traces  in  normal  urine.  A  notable  increase  in  amount 
is  regarded  as  evidence  of  increase  in  intestinal  putrefaction.  It  is 
also  found  in  all  wasting  diseases,  and  in  morbid  states  attended  mth 
rapid  decomposition  of  albuminous  substances,  as  in  empyema.  It  has 
been  particularly  noticed  in  obstinate  constipation  and  obstruction  of 
the  small  intestine.  Occasionally  the  blue  color  of  indican  may  be 
observed  in  urine  soon  after  it  is  passed.  Indican  may  be  detected  by 
the  following  test : 

Add  to  a  sample  of  the  urine  an  equal  volume  of  strong  hydro- 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     655 

chloric  acid,  and  then  a  few  drops  of  a  solution  of  chlorinated  soda. 
A  bluish-black  cloud  is  formed  just  beneath  the  surface  of  the  liquid, 
and  on  stirring  the  reaction  takes  place  throughout  the  mass.  If  the 
liquid  be  shaken  with  chloroform,  the  color  will  pass  into  the  chloro- 
form and  collect  at  the  bottom  of  the  tube.  Care  must  be  taken  not 
to  use  much  chlorinated  soda.  The  depth  of  color  gives  an  approxi- 
mate idea  of  the  amount  of  indican  present. 

Sugar. — This  substance  is  not  a  normal  ingredient  of  urine,  or 
exists  only  in  traces  too  minute  to  be  detected  by  the  ordinary  tests. 
When  met  with  in  normal  urine  it  is  probably  due  to  the  decomposi- 
tion of  the  indican.  Sugar  may  be  found  occasionally  in  the  urine  of 
those  who  live  exclusively  on  a  starchy  diet,'  or  who  take  large  quan- 
tities of  sugar ;  but  the  proportion  even  then  is  very  small.  It  may 
also  form  from  the  breaking  up  of  albuminous  substances.  Sugar  ap- 
pears in  the  urine  after  inhalation  of  carbon  monoxide,  and,  as  this  is 
a  common  ingredient  in  illuminating  gas,  cases  of  light  chronic  poison- 
ing giving  rise  to  apparent  slight  diabetes  are  probably  not  uncommon. 
The  urine  secreted  while  under  the  influence  of  turpentme,  ether, 
chloroform,  chloral,  or  amyl  nitrite  is  found  to  respond  to  the  copper 
tests  for  sugar.  Bordier^  has  grouped  together  many  observations 
which  led  him  to  conclude  that  saccharine  urine  may  be  considered  as 
an  almost  normal  occurrence  in  the  stage  of  recovery  from  acute  dis- 
eases. Measles,  pneumonia,  erysipelas,  all  inflammatory  fevers,  are 
likely  to  exhibit  it  during  convalescence.  It  may  be  detected  in  cer- 
tain lesions  of  the  brain  and  spinal  cord  and  in  phthisis.  But  a  large 
and  persistent  amount  occurs  only  in  diabetes. 

Urine  holding  sugar  in  solution  is  light-colored,  of  high  specific 
gravity,  and  of  peculiar  smell.  It  rarely  deposits  sediments,  and  the 
excess  of  water  in  it  may  be  large. 

To  detect  the  presence  of  sugar,  several  tests  have  been  proposed, 
nearly  all  of  which  are  easy  of  application.  When  albumin  is  present, 
this  should  be  first  separated  by  boiling  and  filtering. 

Trommers  Test. — A  few  drops  of  a  solution  of  copper  sulphate  are 
dropped  into  the  test-tube  holding  the  urine.  Solution  of  caustic  soda 
is  now  added  in  excess.  If  the  fluid  be  saccharine,  the  faint  green- 
ish tint  is  changed  to  a  deep -blue,  the  precipitate  which  is  formed 
when  the  alkali  is  first  added  being  soon  redissolved.  On  heating  the 
blue  mixture  it  becomes  brownish,  then  yellow,  and  finally  a  reddish- 
brown  mass  of  copper  suboxide  is  thrown  down,  very  different  from 
the  flocculent  or  greenish  sediment  noticed  when  no  sugar  exists.     A 

^  Archives  Generales  de  Medecine,  1868. 


656  MEDICAL  DIAGNOSIS. 

very  small  quantity  of  sugar  can  be  detected  by  this  process  ;  but, 
good  as  the  test  is,  it  has  its  drawbacks  ;  for  sugar  is  not  the  only  sub- 
stance which  possesses  the  power  of  reducing  the  salts  of  copper. 
Chloral,  cellulose,  kreatinin,  and  to  some  extent  uric  acid  and  the 
urates,  share  with  it  this  property.  Furthermore,  Beale  has  sho^^m 
that  the  presence  of  ammonium  salts  will  prevent  the  precipitation  of 
the  suboxide  in  urine  containing  but  little  sugar. 

For  the  quantitative  determination  of  sugar,  Fehling's  solution  is 
generally  employed.  This  may  be  made  by  the  follo^^ing  formula,  in 
which,  in  accordance  with  the  recommendation  of  Allen,  the  quantity 
of  Rochelle  salt  is  rather  greater  than  ordinarily  given.  34.64  grammes 
of  pure  crystallized  copper  sulphate  are  dissolved  in  pure  water,  and 
the  solution  is  made  up  to  500  cc.  70  grammes  of  caustic  soda  in  sticks 
and  180  grammes  of  pure  Rochelle  salt  are  dissolved  in  400  cc.  of 
water,  and  this  solution  also  is  made  up  to  500  cc.  The  two  solutions 
should  be  kept  in  separate  well-stoppered  bottles.  For  use  equal  quan- 
tities are  mixed  as  required.  To  determine  the  proportion  of  sugar  in  a 
sample,  five  cc.  of  each  solution  are  mixed,  diluted  with  about  an  equal 
volume  of  water,  and  brought  to  the  boiling-point,  in  a  porcelain  basm. 
The  porcelain  dish  with  handle,  called  a  casserole,  is  very  convenient 
for  this  purpose.  No  precipitate  nor  loss  of  color  should  result  from 
the  boiling  of  the  solution.  The  sample  of  urine  is  then  added  by 
small  portions  at  a  time,  boiling  between  each  addition,  and  watching 
the  liquid  so  as  to  note  the  point  at  which  all  the  blue  color  is  removed. 
The  condition  is  best  determmed  by  withdrawing  the  basin  from  the 
flame  from  time  to  time,  inclining  slightly,  and  allomng  the  red  pre- 
cipitate to  settle.  Any  trace  of  blue  color  is  easily  seen.  Ten  cc.  of 
the  solution  require  .05  gramme  of  glucose  to  reduce  them  completely  ; 
the  amount  of  urine  used,  therefore,  contains  tliis  amount  of  glucose, 
and  a  calculation  of  percentage  can  easily  be  made.  To  get  accurate 
'  results,  the  urine  should  be  quite  dilute,  and  if  the  qualitative  tests 
indicate  considerable  sugar  it  will  be  necessary  to  dilute  the  liquid  to 
five  or  even  ten  times  its  bulk.  This  dilution  must,  of  course,  be 
alloAved  for  when  making  the  final  calculation. 

Allen  recommends  the  following  test  for  cases  in  which  there  may 
be  doubt  as  to  the  presence  of  sugar.  Heat,  to  boiling,  about  ten  cc. 
of  Fehling's  solution,  and  add  a  nearly  equal  quantity  of  the  urine ; 
heat  for  a  few  minutes,  and'  then  set  aside  to  cool.  If  no  turbicUty  is 
produced  as  the  liquid  cools,  the  urine  is  tree  from  sugar,  or,  at  most, 
contains  less  than  ^^  per  cent.  Fehling's  test  can  also  be  used  for 
peptone  and  propeptone.  It  gives  at  the  point  of  contact  in  the  test- 
tube  a  rose-pink  or  purple  color. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     657 

Boettger's  Test. — Add  to  the  filtered  urine  about  half  its  volume  of 
sodium  hydroxide  solution  and  a  pinch  of  pure  bismuth  subnitrate, 
and  boil  the  mixture.  Sugar  mil  be  indicated  by  a  hlaek  precipitate. 
If  sugar  is  not  present,  the  precipitate  will  be  white,  or,  at  most,  some- 
what gray.  This  test  is  very  delicate  and  tolerably  free  from  fallacy. 
Dark-colored  urines  of  high  gravity  may  produce  a  gray  precipitate,  but 
it  does  not  settle  so  rapidly  nor  so  completely  to  the  bottom  of  the  tube. 
Only  a  pure,  finely  powdered  preparation  of  the  bismuth  compound 
should  be  used  for  the  test.  The  bismuth  test  has  an  additional  value, 
because  alcaptone  in  the  urine,  which  reduces  the  Fehling  test  and  thus 
leads  to  the  mistaken  idea  of  the  presence  of  sugar,  does  not  influence  it.^ 

Phenylhydrazine  Test. — Phenylhydrazine  is  a  coal-tar  derivative 
which  possesses  the  property  of  forming  crystalline  compounds  not 
very  soluble  in  water  with  bodies  of  aldehydic  or  ketonic  type,  to  one 
or  the  other  of  which  classes  the  sugars  belong.  It  is  generally  used 
in  the  form  of  phenylhydrazine  hydrochloride.  It  is  said  to  cause  a 
persistent  eczema  when  much  in  contact  with  the  skin.  The  test  may 
easily  be  conducted  without  danger.  The  following  method  seems, 
according  to  some  comparative  experiments  made  by  Leffmann  on  the 
different  published  processes,  to  be  the  best.  Fifty  cc.  of  the  urine  are 
mixed  with  0.75  gramme  of  phenylhydrazine  hydrochloride  and  1.0 
gramme  of  sodium  acetate,  and  the  mixture  is  heated  for  one  hour  at 
least  m  a  test-tube  placed  in  boiling  water.  Very  small  amounts  of " 
sugar  will  produce  a  marked  yellow  precipitate — a  compound  of  sugar 
mth  the  reagent — which  under  moderate  magnifying  power  exhibits 
either  brush-like  branchings  or  more  decidedly  radiate  crystals,  some- 
what like  chestnut-burs.  A  flocculent  brownish  precipitate  or  small 
brown  globules  should  be  disregarded.  The  precipitate  is  almost  char- 
acteristic of  sugar,  but  cannot  by  the  microscope  be  distinguished  from 
a  similar  precipitate  by  glycuronic  acid,  a  rare  substance  which  is 
closely  allied  to  dextrose  in  structure.  The  distinction  can  be  made 
only  by  collecting  the  precipitate  and  determining  its  melting-point. 
The  test,  however,  is  principally  of  value  in  disthiguishing  those  cases 
in  which  very  limited  reducing  action  is  exhibited  by  a  sample  of 
urine  when  tried  by  the  ordinary  tests.  As  a  delicate  reaction  for 
true  sugar  it  does  not  seem  to  possess  the  great  advantage  over  Boett- 
ger's  test  that  has  been  claimed  for  it. 

Further  tests,  though  now  not  much  employed,  are  Moore's  test — 
boiling  the  urine  with  an  equal  part  of  potassium  hydroxide — and  the 
fermentation  test. 

'  Futcher,  Alcaptonuria,  New  York  Medical  Journal,  1897,  ii. 


658  MEDICAL  DIAGNOSIS. 

Other  forms  of  sugar,  such  as  sugar  of  milk,  may  be  found  in  the 
urine.  Sugar  of  milk  has  hitherto  been  detected  only  in  the  urine  of 
lying-in  and  of  nursing  women. 

Acetone. — Ralfe  gives  the  following  test.  About  4  cc.  (one  drachm) 
of  sodium  hydroxide  solution  containing  a  gramme  (fifteen  grains)  of 
potassium  iodide  are  placed  in  a  test-tube  and  boiled.  An  equal 
volume  of  urine  is  then  poured  in  cautiously,  so  as  to  float  on  the 
surface  of  the  alkaline  liquid.  At  the  point  of  contact  a  ring  of  phos- 
phates will  be  formed,  and  after  a  few  minutes  will  be  colored  yellow 
and  studded  with  crystals  of  iodoform.  Alcohol  and  lactic  acid  also 
give  this  result. 

On  adding  a  very  dilute  alkaline  solution  of  sodium  nitroprusside 
to  a  fluid  containing  acetone,  a  ruby-red  color  is  produced  which  in  a 
few  minutes  changes  to  yellow. 

Diacetic  acid,  a  body  somewhat  similar  to  acetone,  is  occasionally 
present  in  urine.  It  is  recognized  by  the  red  color  produced  by  solu- 
tion of  ferric  chloride  in  perfectly  fresh,  unboiled  urine. 

Both  acetone  and  diacetic  acid  are  derivatives  of  betaoxybutyric 
acid,  and  this  itself  results  from  the  disintegration  of  the  tissue  albu- 
mins. Oxybutyric  acid  is  now  very  generally  regarded  as  giving  rise 
to  the  acid  intoxication  that  produces  diabetic  coma.  In  this  it  may 
be  found  in  the  urine  in  enormous  amounts,  100  to  200  grammes  in 
twenty-four  hours. 

The  test  for  oxybutyric  acid  is  with  the  polariscope.  In  thor- 
oughly fermented  urine,  well  filtered,  the  rays  of  polarized  light  are 
deflected  to  the  left.  For  the  quantitative  examination  titration  is 
also  necessary.^ 

Glycuronic  acid  is  formed  by  the  direct  oxidation  of  grape-sugar. 
The  test  for  it  is  to  boil  urine  with  dilute  sulphuric  acid ;  the  liquid 
polarizes  to  the  right.^ 

Inosite. — This  is  a  substance  not  belonging  to  the  sugars,  but 
having  some  of  their  properties,  and  at  times  found  in  the  urine. 
Inosuria  is  a  symptom  rather  than  a  disease.^  The  characteristic  re- 
action of  inosite  is  exhibited  when  a  solution  of  the  substance  is 
evaporated  with  nitric  acid  nearly  to  dryness  on  platinum,  and  the 
residue,  moistened  with  a  little  ammonium  hydroxide  and  a  solution 
of  calcium  chloride,  is  again  evaporated  to  dryness  :  a  marked  rose- 


^  For   the   details   and    much   interesting    matter,    see   Naunyn   on   Diabetes 
Mellitus,  1898. 

2  Paul  Mayer,  Berlin,  klin.  Wochenschrift,  1899,  No.  27. 
^  Gallois,  De  I'lnosurie,  1864. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     659 

color  appears, — which  is  not  the  case  when  true  sugars  are  treated  in 
the  manner  described. 

The  presence  in  the  urine  of  the  blood-extractives  indicates  merely 
the  escape  of  blood-material,  and  proves  the  existence  of  congestion 
or  inflammation  of  some  part  of  the  urinary  surfaces.  Rees  has  pointed 
out^  that  in  Bright's  disease  the  extractives  can  be  found  in  the  urine 
before  albumin  is  met  with,  and  also  that  they  exist  after  the  albumin 
has  disappeared, — thus  warning  us,  on  the  one  hand,  of  the  approach 
of  albuminuria,  and,  on  the  other,  against  too  early  a  belief  in  conva- 
lescence ;  for,  as  he  justly  observes,  so  long  as  the  blood  is  losing  its 
extractives  so  long  is  the  patient  in  peril.  The  presence  of  the  extrac- 
tives also  enables  us  to  diagnosticate  nephritic  irritation  from  renal 
calculus  before  albumin,  blood,  or  pus  has  appeared.  To  the  delicate 
test  by  guaiacum  for  the  crystalloids  of  the  blood,  which  has  been 
used  to  detect  the  prealbuminuric  stag-e  of  Bright's  disease,  we  shall 
presently  more  particularly  refer. 

Albumin  and  other  Proteids. — The  study  of  the  various  proteids 
occurring  in  urine  is  a  matter  of  difficulty  ;  and  much  uncertainty  and 
confusion  still  exist  with  reference  to  them.  The  genito-urinary  tract 
being  a  mucous  area  of  great  extent,  abnormal  secretions  are  frequent, 
and  it  is  in  many  cases  impossible  to  determine  the  boundary  between 
health  and  disease.  Thus,  much  discussion  had  been  held  as  to  the 
occurrence  of  albumin  in  normal  urine,  without  any  clear  definition  as 
to  what  is  meant  by  the  term  normal.  Efforts  have  been  made  to 
secure  tests  of  extreme  delicacy,  but,  while  some  of  these  have  value  in 
physiological  investigation,  they  are  often  too  delicate  for  practical  work. 

By  the  term  albumin,  unqualified,  clinicians  generally  mean  serum- 
albumin,  and  that  meaning  -will  be  understood  in  this  work.  A  pro- 
teid,  derived  from  the  mucous  tissue,  is  generally  present  in  urine. 
This  has  been  designated  mucin,  but  seems  to  be  identical  with  a  body 
called  nucleo-albumin  and  also  obtained  from  bile.  Fibrin  and  hsemo- 
globin  may  appear,  and  also  all  the  products  of  the  transformation  of 
proteids  under  the  influence  of  digestive  ferments,  that  is,  the  various 
proteoses  and  peptones  ;  what  is  often  designated  peptone  is  an  inter- 
mediate product, — an  albumose. 

Albumin  appears  sometimes  for  a  short  period  and  then  for  a  time 
is  not  found.  Egg-albumin,  it  is  stated,  may  show  itself  in  the  urine 
after  the  free  use  of  eggs  as  food. 

The  tests  for  albumin  depend  on  coagulation.  The  most  important 
are: 


1  Guy's  Hospital  Reports,  3d  Series,  vol.  xiv.  p.  431. 


660 


MEDICAL   DIAGNOSIS. 


Heat  J 
Nitric  acid  ; 
Picric  acid  ; 
Potassium  ferrocyanide  ; 
Trichloracetic  acid. 

Heat  Test — Albumin  is  coagulated  by  heat  of  about  150°  F.  (65° 
C).  The  application  of  heat  to  normal  urine  often  causes  a  precipi- 
tate of  phosphate.  To  avoid  this  fallacy  a  small  amount  of  acid,  nitric 
or  acetic,  is  added.  The  test  is  best  performed  as  described  by  Purdy : 
Mix  a  portion  of  the  sample  with  about  one-eighth  its  volume  of  a  sat- 
urated solution  of  common  salt,  filter,  and  fill  a  test-tube  nearly  full 
with  the  mixture.  Add  two  or  three  drops  of  acetic  acid,  and  boil 
the  upper  stratum  of  liquid.  The  contrast  between  the  two  layers  of 
hquid  will  be  sufficient  to  indicate  very  small  amounts  of  albumin. 
The  salt  solution  prevents  the  interference  of  mucin,  which  is  not  pre- 
cipitated under  these  conditions.  This  is  a  satisfactory  method  for  the 
detection  of  minute  amounts  of  albumin.  Small  quantities  may  be 
also  found  by  thorough  boiling  of  urine  to  which  a  few  drops  of  acetic 
acid  have  been  added,  without  admixture  with  the  salt  solution. 

Nitric  Acid,  Heller''s  Test. — Fifteen  drops  of  commercial  nitric  acid 
are  placed  in  a  somewhat  narrow  test-tube,  and  some  urine  poured 
slowly  down  upon  it,  the  tube  being  considerably  in- 
clined. Another  method  is  to  put  the  urine  in  first  and 
introduce  the  acid  by  means  of  a  pipette,  so  as  to  form 
a  clear  layer  at  the  bottom  of  the  tube.  A  white  ring 
forms  at  the  point  of  contact.  Urine  in  which  this  test 
does  not  show  albumin  may  be  regarded,  for  practical 
purposes,  as  not  containing  it. 

Tests  by  the  so-called  underlaying  method  are  con- 
veniently made  by  the  use  of  the  albumin-test  glass  de- 
signed by  Kyner.  The  precipitating  substance,  e.g..,  nitric 
acid,  is  put  in  proper  quantity  in  the  tube,  and  the  liquid 
to  be  tested  is  allowed  to  flow  through  a  filter  folded  in 
the  usual  way  and  placed  in  the  funnel-shaped  top  of 
the  glass. 

In  testing  filtered  urine  it  must  be  borne  in  mind 
that   many   forms    of    filter-paper   Avill   furnish   enough 
soluble  vegetable  albumin  to  give  distinct  reactions  with 
the  more  delicate  tests  for  proteids.     To  avoid  this  error 
it  will  be  best  to  use  the  centrifugal  machine  to  secure  a  clear  liquid. 

Urine  rich  in  urea  sometimes  forms  a  precipitate  of  urea  nitrate. 
It  may  be  distinguished  from   albumin   by  its  crystalline    character, 


Fig 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     661 

especially  after  standing  a  few  hours,  and  by  its  solubility  when  the 
liquid  is  warmed.  Excess  of  urates  may  also  produce  a  precipitate  that 
might  be  mistaken  for  albumin,  but  the  ring  is  irregular  and  will  in  a 
few  hours  become  distinctly  crystalline  and  can  be  easily  determined 
under  the  microscope. 

Resinous  bodies  administered  as  medicines  are  precipitated  by  the 
addition  of  nitric  acid.  They  may  generally  be  recognized  and  dis- 
tinguished from  albumin  by  their  strong  odor  and  by  their  solubility 
in  alcohol. 

In  urine  containing  alkaline  carbonates  an  effervescence  will  occur 
when  any  acid  is  added,  but  this  will  soon  cease  and  the  coagulum  will 
be  formed.  Convenient  ways  of  determining  the  quantity  of  albumin  in 
urine  are  by  Esbach's  albuminometer  and  Purdy's  centrifugal  method. 
The  standard  reagent  for  the  former  is  composed  of  10  grammes  of 
picric  acid,  20  grammes  of  citric  acid,  to  1000  cc.  of  distilled  water. 
After  admixture  with  the  reagent,  the  urine  must  stand  for  twenty-four 
hours.  With  Purdy's  electric  centrifuge  the  test  is  more  accurate,  and 
can  be  completed  in  fifteen  minutes.  Graduated  percentage  tubes  and 
acetic  acid,  and  a  solution  of  potassium  ferrocyanide,  are  employed.^ 

Sometimes  urine  is  encountered  on  which  neither  the  heat  nor  the 
acid  test  yields  the  customary  result.  This  is  owing  to  its  containing 
modified  albumin,  albuminose.  Such  a  case  was  published  by  Bence 
Jones.^  No  coagulation  was  produced  by  heat,  and  none  by  nitric 
acid,  unless  the  urine  was  subsequently  heated  and  permitted  to  cool. 
The  solid  that  formed  on  cooling  disappeared  on  heating.  The  patient 
was  suffering  from  mollifies  ossium.  The  test  as  now  mostly  prac- 
tised consists  in  slowly  heating  slightly  acidulated  urine,  which  be- 
comes cloudy,  but  clears  on  thorough  boiling ;  on  cooling,  the  cloudi- 
ness or  the  deposit  reappears.  Nitric  acid  produces  in  cold  urine  a 
deposit,  which  disappears  on  boiling,  and  reappears  on  cooling.  A 
number  of  late  observations,  especially  those  of  Kahler,  Rosin,  and 
Ellinger,^  have  associated  this  form  of  albuminose  with  multiple  tumors 
of  the  marrow  of  the  bones.  In  a  case  reported  by  Fitz  *  there  was 
also  myxoedema.  Basham  recommends  the  tincture  of  galls  as  a  test 
for  this  modified  form  of  albumin. 

Picric  Acid  Test. — The  saturated  solution  of  this  acid  may  be 
employed  in  the  manner  of  the  nitric  acid  contact  test.  The  solu- 
tion, being  lighter  than  most  urines,  will  form  the  upper  layer.     Picric 

^  Purdy,  Journ.  Amer.  Med.  Association,  Sept.  23,  1899. 
^  Philosophical  Transactions  for  1848. 
3  Deutsches  Arch.  f.  klin.  Med.,  Ixii.,  3  and  4,  1899. 
*  Transactions  of  the  Assoc,  of  Amer.  Phys.,  1898. 


662  MEDICAL  DIAGNOSIS. 

acid  makes  a  very  delicate  test,  but  shows  the  same  fallacies  as  the 
other  acid  tests.  It  also  forms  a  slight  precipitate  with  mucus,  stains 
the  skin  yellow,  and  is  somewhat  explosive. 

Potassium  Fe^Tocyanide  Test. — Twenty-five  drops  of  strong  acetic 
acid  are  thoroughly  mixed  with  three  times  that  amount  of  a  solution 
of  potassium  ferrocyanide  (1  in  20).  A  considerable  volume  of  the 
urine  is  then  added.  Albumin  if  present  will  form  a  precipitate. 
The  test  thus  applied  is  absolute  evidence  of  albumin. 

Trichloracetic  Acid. — This  is  a  solid,  highly  deliquescent  body.  It 
is  corrosive,  and  should  be  handled  with  care.  It  is  employed  in  the 
strongest  possible  solution,  best  obtained  by  allowing  the  solid  to 
absorb  water  from  the  air  until  a  solution  is  just  formed.  It  is  too 
■delicate  a  test  for  general  clinical  work.     It  reacts  with  all  proteids. 

Halliburton  sums  up  the  reactions  for  the  different  proteids  as 
follows : 

"  If  no  precipitate  forms  on  boiling  after  acidulating,  albumin  and 
globulin  are  absent.     A  precipitate  may  indicate  both. 

If  no  precipitate  is  produced  after  neutralizing  the  original  liquid 
and  saturating  with  magnesium  sulphate,  globulin  and  heteroproteose 
are  absent.  If  the  urine  gives  no  precipitate  by  the  boiling  test  for 
albumin,  nor  with  nitric  acid  in  the  cold  nor  when  saturated  with 
ammonium  sulphate,  peptone  is  the  only  proteid  that  can  be  present. 
Peptone  may  be  detected  by  the  so-called  biuret  reaction,  which  de- 
pends on  the  red  color  produced  by  adding  solution  of  sodium  hydrox- 
ide to  the  liquid  to  be  tested  and  then  a  small  amount  of  a  dilute 
solution  of  copper  sulphate.  Other  proteids  react  with  this  test,  but 
give  a  reddish-violet  color. 

The  complete  removal  of  all  the  other  proteids  from  a  mixture 
containing  peptone  by  means  of  ammonium  sulphate  is  difficult. 
Peptone  is  met  with  physiologically  only  during  the  puerperal  state.^ 
It  occurs  pathologically  during  many  varying  conditions,  especially  as 
the  result  of  incomplete  digestion  and  where  there  is  tissue  degenera- 
tion.    It  is  frequent  in  general  paralysis.^ 

Globulin  very  seldom  occurs  in  the  urine  except  in  combination 
with  serum  albumin.  But  in  advanced  disease  of  the  kidneys  its  rela- 
tive proportion  may  be  much  increased.  According  to  Senator  it  is 
most  increased  in  waxy  kidney.     Estelle  ^  met  with  a  number  of  cases 

^  Robitschek,  Zeitschr.  f.  klin.  Med.,  xxiv. 

2  Arch.  Gen.  de  Med.,  March,  1894. 

^  Quoted  by  Hills,  in  a  very  instructive  article  on  the  Proteids  of  the  Urine, 
Boston  Med.  and  Surg.  Journ. ,  Aug.  1899,  which  may  be  also  advantageously  re- 
ferred to  for  the  relative  study  of  the  chemical  tests. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     663 

in  which  giobuKn  was  the  sole  proteid,  GlobuHn  is  insoluble  in  water, 
but  soluble  in  dilute  salt  solutions. 

3Iucin,  Nucleo- Albumin. — The  reactions  of  this  substance  have 
been  studied  especially  by  D.  D.  Stewart.^  He  found  that  solutions 
of  citric  acid,  both  dilute  and  concentrated,  used  by  the  underlaying 
method,  as  in  the  cold  nitric  acid  test  for  albumin,  gave  distinct  contact 
rings.  Picric  acid  associated  with  citric  acid  also  gave  such  precipi- 
tates, but  picric  acid  alone  produced,  Avith  solutions  containing  not 
more  than  .02  per  cent,  of  nucleo-albumin,  only  a  tardily  appearing 
haze.  If  urine  be  diluted  with  water  and  then  strongly  acidulated 
with  acetic  acid,  mucin  is  precipitated,  and  may  be  collected,  redis- 
solved  in  water  by  the  aid  of  alkali,  and  again  precipitated  by  acetic 
acid. 

Blood. — The  passage  of  blood  with  the  urine  constitutes  hsema- 
turia.  The  urine  is  of  a  red  color,  or  of  a  smoky  hue.  If  much 
blood  be  present,  small,  irregular  masses  are  seen  at  the  bottom  of 
the  vessel.  But  the  only  certain  diagnosis  is  by  the  microscope ;  for 
urine  may  be  red  or  black,  from  the  admixture  of  various  pigments 
derived  from  substances  swallowed  as  food  or  medicine,  or  belonging 
to  the  economy.  Thus,  beet-root,  some  kinds  of  strawberries,  log- 
wood, and  rhubarb  impart  a  deep  red  color,  which  may  be  the  cause 
of  groundless  alarm  ;  or  urine  deeply  tinged  with  bile,  or  discolored 
by  fever,  may  be  thought  to  signify  the  occurrence  of  hemorrhage. 

The  chemical  tests  for  blood  are  much  inferior  to  the  microscopic 
examination.  Yet  we  sometimes  may  have  to  resort  to  them.  I 
have  found  a  rough  test  in  the  addition  of  carbolic  acid,  which  not 
only  coagulates  the  albumin,  but  also  changes  the  color  of  the  fluid. 
It  does  not  produce  the  same  peculiar  reddish  tinge  with  bile,  or,  so 
far  as  I  have  tried,  with  any  other  substance.  The  guaiacum  test  is 
very  accurate.  It  is  especially  valuable  in  the  recognition  of  the  pre- 
albuminuric  stage  of  Bright's  disease,  in  which  h£emoglobin  appears 
in  the  urine  before  albumin.^  The  test,  as  modified  by  Stevenson, 
consists  in  adding  to  a  few  drops  of  urine  in  a  small  test-tube  a  drop 
of  tincture  of  guaiacum  and  then  a  few  drops  of  ozonic  ether.  The 
mixture  is  agitated,  and  as  the  ether  collects  at  the  top  it  carries  with 
it  the  blue  color  produced  by  the  haemoglobin,  leaving  the  urine 
colorless  below.  If  saliva  or  a  salt  of  iodine  be  present,  the  test  is 
fallacious.  The  spectroscope  affords  a  very  delicate  test.  The  char- 
acteristic bands  of  haemoglobin  of  yellow  and  green  are  seen  between 

1  Medical  News,  July,  1894. 

^  Mahomed,  Medico-Chirurgical  Transactions,  1874. 


664  MEDICAL  DIAGNOSIS. 

D  and  E.  If  the  haemoglobin  be  in  a  state  of  destruction  or  reduction, 
only  one  broad  band  appears. 

But  the  microscope,  as  already  stated,  is  the  means  most  employed 
and  most  valuable.  The  corpuscles  we  detect  are  often  crenated,  or 
very  pale,  and  sometimes  very  small,  but  never  collected  in  rouleaux ; 
there  is  often  considerable  granular  pigment.  After  having  determined 
that  hsematuria  exists,  the  questions  ■  remain  to  be  solved,  at  what 
point  has  the  blood  been  poured  out  ?  Is  it  really  from  the  urinary 
organs  ?  and  if  it  be  from  them,  whence  ? — from  the  kidneys,  from 
the  bladder,  or  from  some  other  portion  of  the  tract  ?  ■  Again,  what 
morbid  state  lies  at  the  root  of  the  hemorrhage  ? 

Now,  the  first  of  these  questions  must  always  be  answered  at  the 
onset.  Blood  may  flow  from  the  vagina  or  uterus  and  become  mixed 
with  the  urinary  secretion,  or  it  may  have  been  added  for  purposes  of 
deception.  In  the  former  case,  a  careful  inquiry  into  the  state  of  these 
organs,  or,  if  necessary,  a  digital  examination,  will  eliminate  the  source 
of  error ;  in  the  latter,  drawing  off  the  urine  by  the  catheter  will  detect 
the  imposture.  When  we  have  fully  satisfied  ourselves  that  the  blood 
is  derived  from  the  urinary  organs,  the  next  point  to  be  ascertained  is 
whether  it  proceeds  from  the  kidney  or  from  the  bladder.  To  deter- 
mine this,  we  have  not  only  to  study  the  character  of  the  fluid  excreted^ 
but  also  to  investigate  all  the  conditions  of  the  accident. 

If  the  blood  come  from  the  Madder^  it  is  not  equally  diffused  through 
the  urine ;  the  fluid  discharged  is  at  first  clear  or  nearly  so,  but  at  the 
end  of  the  act  of  micturition  is  much  more  deeply  colored ;  or  pure 
blood,  in  a  liquid  form  or  in  clots,  is  voided.  Then,  too,  there  is  usu- 
ally pain  over  the  bladder,  with  a  frequent  desire  to  pass  water,  and  a 
stoppage  in  doing  so  ;  the  urine  is  generally  alkaline. 

When  the  blood  is  derived /rom  the  kidney^  we  mostly  discover  pain 
in  the  lumbar  region,  and  other  symptoms  pointing  to  the  affected 
organ,  the  existence  of  albumin  in  considerable  quantities  in  the  urine, 
or  the  passage  of  gravel.  Clots  are  not  encountered  in  renal  hemor- 
rhage, except  when  the  blood  coagulates  in  the  infundibulum  or  the 
ureter  and  is  gradually  forced  downward.  Such  clots  are  of  a  whitish 
color,  and  generally  of  cylindrical  shape.  In  their  passage  towards 
the  bladder  and  out  of  the  urethra  they  become  often  the  source  of 
distressing  pain.  They  are  very  significant,  yet  they  are  not  absolutely 
pathognomonic  of  renal  hemorrhage  ;  for  coagula  formed  in  the  blad- 
der may  be  retained  there  for  some  time,  and  lose  their  color  before 
they  are  expelled.  Sometimes  we  meet  with  little  solid  or  gelatinous 
fibrinous  coagula  which  bespeak  simply  localized  fibrinous  exudation 
from  some  part  of  the  urinary  passages. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     665 

Aid  in  diagnosis  may  be  derived  from  the  study  of  the  shape  of 
the  clots,  which  for  this  purpose  should  be  floated  out  in  water. 
According  to  Hilton/  they  will  oftentimes  be  exact  moulds  or  casts  of 
the  cavity  in  which  the  blood  was  effused.  Thus,  coagula  formed 
within  the  bladder  have  a  somewhat  irregular,  circular  outline,  and 
are  flattened  in  shape,  with  bevelled  and  serrated  edges.  The  use  of 
the  microscope,  furthermore,  is  very  valuable  in  the  differential  diag- 
nosis. The  epithelium  which  is  mixed  with  the  blood  from  the  kidney 
is  not  flat  and  in  scales,  like  that  from  the  bladder,  but  small  and  more 
or  less  round  or  columnar ;  nor  are  there  fibrinous  shreds.  Some- 
times the  blood-corpuscles  are  observed  to  be  collected  on  casts  that 
have  been  moulded  within  the  renal  tubes.  These  blood-casts  warrant 
an  absolute  conclusion  as  to  the  source  of  the  hemorrhage. 

Renal  Hcematuria. — When  of  renal  origin,  the  haematuria  is  often 
due  to  congestion  or  an  acute  parenchymatous  inflammation  of  the 
kidneys  in  infectious  maladies,  such  as  scarlatina,  smallpox,  malignant 
measles,  and  typhus.  Here  we  have  the  history  of  the  malady,  and 
the  presence  of  tube-casts,  of  blood-casts,  and  of  a  considerable  amount 
of  albumin,  to  explain  the  meaning  of  the  hemorrhage.  The  blood  is 
derived  from  the  engorged  and  ruptured  Malpighian  corpuscles.  It  has 
been  stated^  as  a  diagnostic  sign  that  in  renal  haematuria  the  blood- 
corpusles  show  fragmentation,  similar  to  the  irregularities  of  poikilo- 
cytosis,  while  this  does  not  happen  in  vesical  hemorrhage.  But  as 
regards  the  large  amount  of  albumin  present,  we  must  not  lay  too 
much  stress  on  this  as  indicating  marked  kidney  implication.  Irritant 
medicines,  such  as  turpentine  and  cantharides,  may  cause  congestion 
and  bloody  urine ;  and  so  do  strains  and  blows  on  the  back.  In  all 
these  varied  circumstances,  a  careful  survey  of  the  history  and  the 
.symptoms  will  establish  the  diagnosis. 

Renal  haematuria  of  chronic  character  is  generally  due  to  cancer 
of  the  kidney ;  to  cystic  degeneration ;  to  ulceration  within  the  pelvis 
of  the  organ  ;  ■  or  to  irritation,  with  or  without  ulceration,  set  up  by  a 
calculus.  In  the  first  of  these  affections  there  is  nothing  in  the  urine 
to  point  out  the  source  of  the  haematuria  until  the  disease  is  far  ad- 
vanced, when  pus,  and  sometimes  disorganized  cancerous  tissue,  may 
be  discerned  in  the  sediment.  The  manifestations  of  cystic  degenera- 
tion are  uncertain  unless  we  can  detect  a  large  tumor ;  the  signs  of  a 
non-calculous  pyelitis  are  not  definite,  but  haematuria  is  a  rare  symp- 
tom.     The  existence  of  a  calculus — the  most  common  of  the  causes 


^  Guy's  Hospital  Reports,  3d  Series,  vol.  xiii.  p.  19  et  seq. 
'^  Gumprecht,  Deutsch.  Archiv  f.  klin.  Med.,  liii.  1894. 


Q6e  MEDICAL  DIAGNOSIS. 

producing  chronic  hsematuria — is  indicated  as  the  source  of  the  hemor- 
rhage by  locaHzed  pain,  leucocytes  in  the  urine,  and  by  the  bleeding 
having  followed  active  exertion,  or  a  jar  of  the  body  from  a  fall,  and 
by  its  recurring  from  time  to  time  under  circumstances  like  those  just 
mentioned,  favorable  to  the  disturbance  of  a  calculus  lodged  in  the 
kidney.  We  find  also  heematuria  in  tubercular  disease  of  the  kid- 
neys ;  as  in  cancer,  it  is  apt  to  be  intermittent.  Haematuria  is  at 
times  met  with  in  interstitial  nephritis.  Then  there  is  a  form  of  hge- 
maturia  unconnected  with  any  obvious  lesion,  and  apparently  of 
neurotic  origin,  to  which  Klemperer  and  Harris  have  especially  called 
attention. 

Hcemoglobinuria,  or  paroxysmal  hcemoglobiniiria,  as  it  is  in  its  most 
marked  form,  differs  from  ordinary  renal  hemorrhage :  the  urine, 
although  coagulable  by  heat  and  nitric  acid,  exhibits  very  few  or  no 
blood-corpuscles,  but  shows  much  granular  pigment ;  there  is  blood 
dissolution,  and  only  the  blood  coloring-matter  is  found  in  the  urine  ; 
with  the  haemoglobin  is  generally  methEemoglobin.  We  may  use  the 
guaiacum  test  to  develop  the  presence  of  the  dissolved  blood-cells  ; 
the  haemin  crystals  of  Teichman  can  be  produced,  and  with  the  spec- 
troscope we  find  the  oxy haemoglobin  bands  between  D  and  E,  occa- 
sionally also  the  metliEemoglobin  bands  in  the  red.  The  urine  voided 
is  generally  of  a  deep  blood-color,  and  within  an  hour  or  two,  per- 
haps, changes  suddenly  to  a  pale  straw-color.  It  shows  an  increased 
proportion  of  urea.  According  to  Greenhow,^  crystals  of  calcium 
oxalate  are  constantly  passed  during  a  paroxysm,  and  are  absent  at 
other  times.  The  affection  is  unattended  by  any  permanent  lesion  of 
the  kidneys.  It  is  paroxysmal  in  form,  but  not  of  malarious  origin. 
It  is  ushered  in  by  a  chill ;  in  some  instances  immoderate  yawning 
and  stretching  of  the  limbs  are  the  initiatory  symptoms,  and  urticaria, 
great  thirst,  and  local  cyanotic  appearances  are  observed.  There  is, 
indeed,  a  close  association  with  Raynaud's  disease.  The  temperature 
may  be  normal  or  elevated.  Transitory  albuminuria  m'ay  precede  the 
attacks  ;  between  them  the  urine  is  normal.  Pain  in  the  loins  is  not 
unusual.  In  the  blood  during  the  attack  a  marked  diminution  of  red 
corpuscles  is  observed,  as  well  as  masses  of  granules  and  spindle- 
shaped  bodies  and  other  products  of  destructive  change  ;  and  it  is 
very  likely,  as  Ponfick  maintains,  that  the  blood  condition  is  primary 
and  the  haemoglobinuria  secondary :  haemoglobin  in  the  blood-serum 
always  precedes  the  haemoglobin  in  the  urine.  The  etiology  of  the 
disease  is  unknown.     It  often  happens  in  syphilitic  subjects.     In  those 

^  Transactions  of  the  Clinical  Society,  1868,  vol.  i, 


THE  UEINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     667 

predisposed,  brain-worry  brings  on  attacks  ;  rest  and  food  may  pre- 
vent them.     The  influence  of  cold  seems  to  be  a  very  potent  cause.^ 

Hsemoglobinuria  also  occurs  in  a  non-paroxysmal  form,  as  after 
extensive  burns,  or  due  to  toxic  causes,  such  as  poisoning  by  chlorate 
of  potassium,  carbolic  acid,  naphthol,  pyrogallic  acid,  salol,  arseniu- 
retted  hydrogen.  The  poisons  of  the  infective  fevers,  such  as  scarlet 
fever,  typhoid  fever,  yellow  fever,  may  also  occasion  it. 

There  is  an  intermittent  haematuria  which  is  malarial.  This 
malarial  hcemafuria  may  occur  in  daily  paroxysms,  or  at  longer  but 
regular  mtervals.  The  bleeding  sets  in  suddenly.  The  urine  is  albu- 
minous, contains  casts,  haemoglobin,  and  generally  only  few  blood- 
disks  ;  it  shows  a  hasmoglobinuria  rather  than  a  haematuria.  The 
attacks  are  mostly  preceded  by  coldness  of  the  extremities  ;  elevation 
of  temperature  follows.  When  there  are  distinct  fever  and  yellowness 
of  skin,  the  hemorrhage  from  the  kidney  forms  part  of  the  disease 
known  as  hemorrhagic  malarial  fever,  which  will  farther  on  receive 
more  detailed  consideration.  Malarial  haematuria  is  more  common  in 
men  than  in  women.^  It  differs  from  ordinary  paroxysmal  hgematuria 
above  described  in  the  greater  regularity  of  the  paroxysms,  and  in  the 
influence  quinine  exerts  on  them,  though  by  some  qumine  is  regarded 
as  the  cause  of  the  hsematuria.  Malarial  organisms  are  especially 
found  in  the  blood. 

There  is  also  a  form  of  haematuria  which  is  endemic  and  depends 
upon  the  presence  of  a  parasite^  Bilharzia  haematobia.  It  prevails  in 
the  Mauritius,  certain  parts  of  Cape  Colony,  Natal,  Egypt,  and  Brazil. 
The  parasite  inhabits  mainly  the  small  vessels  of  the  mucous  mem- 
brane of  the  urinary  passages  and  the  kidneys,  and  it  gains  access 
to  these  parts  chiefly  during  the  act  of  bathing  in  rivers.  Persons 
affected  with  the  Bilharzia  haematobia  are  often  observed  to  pass  small 
renal  calculi  of  calcium  oxalate  having  for  their  nuclei  the  ova  of  this 
parasite  ;  ^  they  may  also  present  chylous  urine.  A  similar  jjarasitic 
hcematuria,  due  to  the  Filaria  sanguinis  hommis,  is  met  with  in  India. 

Further,  there  is  a  haematuria  peculiar  to  infants.  This  has  been 
described  by  Parrot,*  under  the  name  of  renal  tubal  hcematuria,  and  is 

1  Rosenbach,  Berlin,  klin.  Wochensch. ,  1880;  Mackenzie,  Lancet,  Feb.  1884. 

•*  Tyson,  System  of  Pract.  Med.  by  Amer.  Authors,  vol.  iv.  ;  see  also  Baker, 
Prize  Essay,  North  CaroUna  Med.  Journ.,  1887  ;  J.  A.  Stamps,  Therap.  Gaz.,  1888, 
3d  Series,  iv. 

^  Geo.  Harley,  Med.-Chir.  Transact.,  vol.  xlvii.  p.  55,  and  vol.  Hi.  p.  379; 
Handford,  Brit.  Med.  Journ.,  1887  ;  Allen,  London  Practitioner,  April,  1888,  and 
Hill,  London  Lancet,  May,  1888. 

*  Archives  de  Physiologie,  Sept.  1873. 


668  MEDICAL   DIAGNOSIS. 

characterized  by  hEematuria  and  the  accumulation  in  the  tubules  of 
the  kidney  of  the  red  globules  of  the  blood,  and  by  a  bronze  discol- 
oration of  the  skin,  and  cephalic  symptoms. 

Besides  these  causes,  renal  hemorrhage  may  occur  from  rupture 
of  the  kidney,  of  which  it  is  the  most  prominent  sign.  It  may  also 
result  from  an  altered  state  of  the  blood,  as  in  purpura  and  in  scurvy 
or  in  leukaemia ;  or  we  may  find  hsemoglobinuria  in  these  states. 

Vesical  Hcematuria. — One  source  to  which  this  may  be  owing  is  a 
congestion  of  the  bladder,  as  witnessed  in  fevers  of  a  low  type  ;  another 
is  irritant  diuretics  ;  another  is  blood-effusion  from  purpura  or  the 
hemorrhagic  diathesis.  Yet  another  is  inflammation,  whether  acute  or 
chronic,  and  whether  of  traumatic  origin  or  brought  on  by  a  stone. 
In  most  of  these  contingencies  the  history  of  the  case  and  the  local 
symptoms  establish  the  diagnostic  distinctions  ;  in  arriving  at  which 
we  are  often  materially  aided  by  the  introduction  of  a  sound  into  the 
bladder.  In  hemorrhage  from  the  bladder,  dependent  upon  tumor  or 
mahgnant  growths,  there  is  generally  also  purulent  urine  ;  the  appear- 
ance of  blood  in  the  urine  may  be  the  first  sign  of  disease.^ 

Vesical  hsematuria,  more  frequently  than  renal,  occurs  as  a  vica- 
rious discharge.  Persons  who  are  subject  to  bleeding  piles  lose  blood 
occasionally  from  the  bladder  instead  of  from  the  rectum.  But  true 
vesical  hemorrhoids  are  not  uncommon. 

Blood  may  be  discharged  from  other  parts  of  the  urinary  appa- 
ratus ;  it  may  come  from  the  jyostate  gland  or  from  the  urethra.  Now, 
in  either  case  the  bleeding  is  usually  profuse,  and  large  quantities  of 
blood  are  passed  pure,  or  unmixed  with  urine.  Besides,  the  local  signs 
furnish  important  points  of  discrimination. 

Hgematuria  itself  is  very  rarely  fatal.  One  of  the  worst  conse- 
quences it  may  entail  is  the  retention  of  a  clot  which  serves  as  a 
nucleus  for  the  formation  of  a  calculus. 

Pus.— Vrine  containing  pus  deposits  an  opaque  creamy  sediment 
or  a  glairy  mass,  is  generally  alkaline,  and  always  slightly  albuminous. 
If  the  deposit  be  agitated  with  a  strong  solution  of  caustic  soda  it 
becomes  gelatinous.  This  is  the  chemical  test  for  pus.  But  it  is  a 
c'lumsy  one,  compared  with  the  rapid  and  absolute  diagnosis  by  means 
of  the  microscope.  With  the  leucocytes  we  find  considerable  epithe- 
lium from  the  bladder  or  the  pelvis  of  the  kidney. 

A  deposit  of  phosphates-  may  be  mistaken  for  pus  ;  a  few  drops  of 
acetic  acid  clear  it  up,  but  do  not  influence  pus.  Sometimes  a  large 
amount  of  mucus  is  mixed  with  the  purulent  sediment,  or  a  deposit 


1  See  case  by  Todd,  Case  XI.,  Lectures  on  Urinary  Diseases. 


THE  URINE,  AND  DISEASES  OF  THE  UBINARY  ORGANS.     669 

due  wholly  to  the  former  ingredient  is  so  considerable  that  it  is  mis- 
taken for  pus.  Yet  the  mucous  deposit  shows  distinct  points  of  differ- 
ence :  it  is  less  dense,  and  collects  more  in  clouds  at  the  bottom  of  the 
vessel ;  and  it  does  not  under  any  test  show  albumin.  Again,  the 
microscope  is  a  valuable  means  of  discrimination.  In  place  of  leuco- 
cytes, quantities  of  epithelium  are  always  seen  to  be  entangled  in  the 
transparent  mucus,  and  the  action  of  acetic  acid  develops  the  fila- 
ments of  mucin.  Sometimes,  also,  there  are  thin  flakes  of  cylindrical 
bodies,  unlike  any  appearance  exhibited  by  pus.  Yet,  when  the  urine 
is  strongly  ammoniacal,  even  the  microscope  does  not  furnish  a  certain 
test ;  for  the  salts  of  ammonia  obliterate  the  distinctive  pus-globules 


Fig.  63. 


00 


Leucocytes  in  the  urine :  those  at  the  lower  part  of  the  field  exliihit  the  action  of  acetic  acid  on  the 

corpuscles. 

and  convert  pus  into  a  slimy  mass,  in  which  nothing  but  the  nuclei 
may  be  distinguishable. 

As  to  the  exact  seat  of  the  formation  of  the  pus,  its  existence  in 
the  urine  affords  no  clue.  When  the  leucocytes  are  round  and  well 
developed,  with  their  characteristic  nuclei  readily  brought  out  by 
acetic  acid,  they  generally  have  their  origin  in  a  catarrhal  inflamma- 
tion of  the  mucous  membrane  of  the  bladder,  and  are  apt  to  be  asso- 
ciated with  triple  phosphates.  On  the  other  hand,  pus-corpuscles  of 
irregular  contour,  exhibiting  irregular  nuclei  when  tre_ated  with  acetic 
acid,  and  very  granular,  partly  destroyed  cells,  indicate  the  probable 
existence  of  deep-seated  suppuration,  ulceration,  or  tubercular  dis- 
ease ;  and  in  this  we  find  also  tubercle  bacilli.  The  sudden  appear- 
ance in  the  urine  of  large  quantities  of  pus  points  to  the  bursting  of  an 

42 


670  MEDICAL   DIAGNOSIS. 

abscess  :  an  abundant  deposit  of  pus  in  acid  urine  is  chiefly  noticed 
in  pyelitis.  In  all  instances  we  must  be  certain  that  the  pus  in  the 
urine  is  not  from  a  urethritis  or  a  vaginal  discharge.  To  be  sure  in 
the  latter  case  the  urine  must  be  exammed  after  catheterization. 

Fat. — Fatty  matter  may  occur  in  the  urine  in  various  forms  and  in 
different  conditions.  It  may  be  found  in  the  shape  of  globules,  when 
oil  or  milk  has  been  added  to  the  urine  for  purposes  of  deception,  or 
when  the  former  article  has  been  swallowed  for  some  time  in  consid- 
erable quantities,  as  for  instance  during  the  administration  of  cod-liver 
oil.  Fat  is  also  encountered  in  globules  of  varying  size,  either  free,  in 
cells,  or  in  tube-casts,  as  in  fatty  degeneration  of  the  kidneys.  Fat, 
too,  may  be  found  in  the  urine  in  cases  of  chronic  suppuration,  phos- 
phorus poisoning,  and  in  fat  embolism  after  fractures. 

The  tests  for  fat  are  its  solubility  in  ether,  and  its  microscopical 
characters.  Lee  and  Atlee  have  pomted  out  ^  an  illusory  detection  of 
fat.  They  found,  in  testing  a  specimen  of  urine,  that  the  ether  rose  to 
the  top  so  charged  with  matter  as  to  resemble  a  half-liquid  pomade. 
Separated  by  a  pipette  and  spontaneously  evaporated,  it  left  a  dirty- 
white  gxeasy  mass.  A  careful  examination  of  this  residue  showed 
that,  instead  of  consisting  of  fatty  acids,  it  contained  nothing  but  the 
normal  constituents  of  the  urine,  for  it  was  soluble  in  water,  reap- 
pearing as  normal  urine.  It  was  then  ascertained  that  almost  any 
urine  wAW  form  an  emulsion  when  violently  agitated  with  ether,  espe- 
cially if  the  ether  contain  a  small  amount  of  alcohol.  When,  there- 
fore, ether  appears  to  dissolve  out  fatty  matter  from  urine,  the  ethereal 
solution  should  be  separated,  and  allowed  to  evaporate  spontaneously, 
and  if  the  residue  be  soluble  in  water  it  cannot  be  held  to  contain 
fat. 

There  is  no  certainty  of  the  presence  of  fat  unless  the  sedmient  be 
examined  chemically  and  microscopically.  The  opalescence  of  urine 
caused  by  a  sediment  of  urates  has  been  mistaken  for  that  from  oily 
matter,  and  so  also  has  been  the  pellicle  which  often  forms  on  urine, 
and  which  consists  not  of  fat,  but  of  vibriones,  fungi,  and  crystals  of 
the  triple  phosphates.  The  "  kyestein"  pellicle  observed  in  the  preg- 
nant state  is  of  similar  kind,  though  some  oily  matter  may  enter  into 
its  composition. 

In  some  cases  fat  is  met  with  in  a  very  finely  divided  state,  im- 
parting to  the  urine  a  milky  look,  Avhich  disappears  on  its  admixture 
with  ether.  This  condition,  to  which  the  name  chylous  urine  has  been 
given,  does  not  depend  upon  any  permanent  morbid  change  in  the 

^  Amer.  Journ.  Med.  Sci.,  A^jril,  1869,  p.  357. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     671 

kidney ;  the  chylous  character  of  the  urine  is  intimately  connected 
with  the  absorption  of  chyle,  but  precisely  how  the  urine  acquires 
that  character  is  uncertain.  It  may  be  absent  in  the  day  urine  and 
very  marked  in  the  night  urine  ;  there  are  at  times  small  quantities  of 
albumin  present.  The  affection  may  continue  for  years  without  im- 
pairment of  the  general  health,  being  always  perceptibly  increased  by 
exercise.  In  the  tropics  chylous  urine  is  found  often  in  connection 
with  the  Filaria  sanguinis  hominis. 

A  urine  which  spontaneously  coagulates  soon  after  being  voided, 
omng  to  iibrin,  a  fibrinuria,  is  very  uncommon  except  in  the  Isle  of 
France  and  in  Brazil.  A  thick  urine  may  be  due  to  pus  dissolved  in 
alkahes,  as  in  certain  bladder  affections.  But  the  thick  matter  is  at 
once  greatly  thinned  by  water,  and  on  the  addition  of  acetic  acid  a 
white  precipitate  of  alkaline  albuminate  falls. ^ 

Sediments. — In  connection  with  the  ingredients  of  the  urine,  the 
nature  of  the  urinary  sediments  has  been  discussed,  and  it  has  been 
insisted  that  they  cannot  be  accurately  determined  save  by  a  micro- 
scopical examination.  I  shall  here  group  together  only  their  general 
characteristics : 

1.  A  light  and  flocculent  cloudy  deposit  is  commonly  mucus, 
entangling  epithelial  cells,  bacteria,  or  spermatozoa. 

2.  A  dense,  abundant,  white  deposit  is  generally  composed  of 
urates  or  phosphates  ;  but  it  may  be  pus  or  extraneous  matter. 

3.  A  yellow  or  pink  deposit  is  almost  always  due  to  urates. 

4.  A  granular  or  crystalline  deposit,  of  reddish  or  dark-brown 
color  and  small  in  quantity,  is  uric  acid. 

5.  A  dark,  sooty  or  dingy-red  deposit  is  blood. 

6.  A  blue  deposit  is  indican. 

The  following  table  may  serve  a  useful  purpose,  in  showing  how 
both  the  sediments  and  the  soluble  urinary  ingredients  are  affected 
by  the  reagents  commonly  employed  : 


Table  exhibiting  the  Significance  of  the  Main  Conditions  and  the  Action  of  the 
Main  Reagents  employed  in  the  Examination  of  the  Urine. 

(  Urine    high-col-   f  Increase   of   urea, 

'^^^"- \        ored 1       uric  acid,  etc. 

^  Urine  pale Diabetes. 

f  Urine   high-colored   f  Certain    forms    of 

Low J       or  normal i      Bright' s  disease. 

(  Urine  pale Excess  of  water. 


Specific  Gravity 


^  Hol'inunn  and  Ultzmann,  op.  dt. 


672 


MEDICAL  DIAGNOSIS. 


Table  exhibiting  the  Significance  of  the  Main  Conditions  and  the  Action  of  the 
Main  Reagents  employed  in  the  Examination  of  the  Urine. — Continued. 


Nitric  Acid  - 


Heat ) 


Throws  down  de- 
posit   


Phosphates. 


Dissolves  deposit . 
Does  not  dissolve 


Soluble     in     nitric 

acid 

Insoluble    in  nitric  j  Serum-albumin. 

acid \  Serum-globulin. 

Urates. 
Uric  acid. 


deposit i  Phosphates 

Precipitates  .... 


Quickly Albumin. 

Uric  acid 
More  gradually 


Urea      nitrate 
(crystalline). 


Dissolves 


Produces   play  of 

color  

Turns  black  .... 


Earthy  phosphates. 
Alkaline  phos- 
phates. 
Oxalates. 

V  Bile-pigment. 

Melanin. 


Hydrochloric 
Acid 


Precipitates Uric  acid. 

Transforms   ....  1  Urates    into 

{       acid. 

Change  of  color  to  -j 

viQlet r  Uroxanthin. 

To  bluish 

Admixed    chloro- 
form    becomes  \  Indicans. 
bluish  or  violet.  J 


Sulphuric    Acid 


Changes    color  of 
urine 


Brown Urohaematin. 

Crimson    or    violet  \ 
<;        (if     sugar     have   I  Biliary  acids. 
I        been  added)  .  .  .  j 
V  Violet Indican. 


Acetic  Acid  . 


Precipitates  de-  -> 
posit  (n.ot  solu-  I 
ble  in  excess  of  [ 
the  acid) J 

Precipitates  with 
potassium  ferro- 
cyanide  


Mucin    (nucleo- 
albumin). 

Albumin  and  albu- 
moses. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     673 


Table  exhibiting  the  Significance  of  the  Main  Conditions  and  the  Action  of  the 
Main   Reagents  employed  in  the  Examination  of  the  Urine. — Continued. 


Picric  Acid 


Precipitates 


Albumin,  albu- 
moses,  peptones. 

Red  deposit, — 
blood. 

Slowly-developed 
haze, — mucin. 


Sodium  Hydroxide  .  < 


Ammonium 

Hydroxide   .  . 


Barium  Chloride 


On  boiling,    turns  |  g^^^^_ 

urine  brown  .  .  j 

f  Uric  acid. 

Dissolves I  jj^p^g.^^  ^f  ^^,^tgg_ 

Forms   gelatinous  ] 

mass I 

Precipitates   ....       Earthy  phosphates. 
Dissolves Cystin. 


Precipitates 


Deposit,  soluble  in  |  p^^^^  ^^^^^^^ 

free  acid ) 

Deposit,     insoluble  )_,,,, 

r       . ,  \  Sulphates, 

m  acids j 


Silver  Nitrate  . 


Precipitates 


Yellow  deposit, 
soluble  in  ni- 
tric acid  and 
ammonia 

i  White  deposit, 
insoluble  in 
nitric  acid,  but 
soluble    in    am- 

l      monia 


Alkaline      phos- 
phates. 


>  Sodium  chloride. 


Copper  Sulphate 
AND    Sodium    Hy-  < 
DROXIDE 


Ether 


Precipitates    with  1 

heat  yellowish-   ^  Sugar 
red  deposit . 


Turns  violet 

f  Precipitates 
Dissolves  .  . 


Bromine  Water 


-I 


Does  not  dissolve 

Turns    urine   yel 
low,  then  black 


I  In  cold Peptone. 

i  With    heat Serum-allnimin. 

Albumin. 
{  Hippuric  acid,  sol- 
\        ui)l('  ill  alcohol. 
y  Fat. 

Uric  acid. 

[  Melanin. 


674  MEDICAL  DIAGNOSIS. 

Toxicity  of  the  Urine. — The  human  urine  is  toxic,  and  the  toxicity 
varies  under  diet  and  in  disease.  The  substances  in  the  urine  pro- 
ducing the  poisonous  effects  are  the  potassium  salts,  phenol  deriva- 
tives, unknown  products  of  metabolism,  coloring  substances,  as  well 
as  toxines  obtained  from  various  forms  of  bacterial  infection.  The 
toxicity  is  reduced  by  prolonged  fasting  and  by  a  milk  diet,  although 
Lapicque  and  Marette  ^  found  that  after  the  third  day  of  exclusive  milk 
diet  it  was  again  increased.  The  toxicity  of  human  urine  is  reduced 
in  anaemia ;  ^  the  urine  is  also  less  toxic  than  normal  in  tuberculous 
lepers.^  On  the  other  hand,  the  toxicity  of  the  urine  is  increased  in 
cholera  and  in  other  infectious  diseases,  as  well  as  in  certain  liver 
affections,*  such  as  in  atrophic  alcoholic  cirrhosis,  in  tuberculosis,  car- 
cinoma, some  forms  of  chronic  icterus,  and  in  hypertrophic  cirrhosis. 
It  is  normal  or  diminished  in  hypertrophic  alcoholic  cirrhosis,  in  con- 
ditions secondary  to  heart  lesions,  and  in  infectious  icterus  until  the 
crisis,  when  it  augments.  Permanent  increase  is  of  grave  prognosis, 
as  it  indicates  destruction  of  liver-substance  and  function.  The 
process  of  suppuration  also  increases  the  poisonous  effect  of  the 
urine.^  The  toxicity  of  the  urine  is  decreased  in  cases  of  puerperal 
eclampsia,  whereas  the  toxicity  of  the  serum  of  the  blood  is  increased, 
,as  discovered  by  Bouchard,  and  confirmed  by  Ludwig  and  Savor.^ 
The  observation  that  the  urine  of  epileptics  is  less  toxic  immediately 
preceding  and  during  a  fit,  or  series  of  fits,  and  hypertoxic  after  the 
attack,  has  been  made  by  Voisin  and  Peron.^  The  urine  of  epilep- 
tics affected  with  mental  disorder  is  also  constantly  less  toxic.  These 
observers  therefore  claim  that  by  frequent  estimation  of  the  urinary 
toxicity  it  may  be  possible  to  predict  the  occurrence  of  a  fit,  to  de- 
termine whether  or  not  a  series  has  terminated,  or  if  mental  disturb- 
ance is  likely  to  follow. 

The  method  pursued  in  order  to  determine  the  relative  toxicity 
of  the  urine  is  to  take  a  certain  quantity  of  the  mixed  urine  of  the 
preceding  twenty-four  hours,  filter  it,  and  render  it  alkaline,  pre- 
cautions being  taken  to  avoid  bacterial  contamination.  The  urine  is 
then  slowly  injected  into  a  vein  in  the  ear  or  the  leg  of  a  rabbit  or 


1  Le  Bulletin  Medical,  July  25,  1894. 

^  Piccini  and  Conti,  Revue  des  Sciences  Med.  en  France  et  a  I'Etranger,  Paris, 
1894. 

*  Chartiniere,  Annales  de  Dermatologie  et  de  Syph.,  March,  1895. 

*  Surmont,  La  Semaine  Med.,  Paris,  Jan.'  20,  1892. 
'"  Nannati  and  Baiocchi,  Riforma  Med.,  1892. 

«  Monatshefte  fur  Geburtsh.  und  Gyniik.,  1895. 
■^  Archives  de  Neurologie,  Paris,  1892. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     675 

guinea-pig.  Death  of  the  animal  follows  after  several  ounces  have 
been  injected.  By  dividing  the  entire  daily  excretion  of  urine  by  the 
amount  recj[uired  to  produce  the  lethal  result  (in  cubic  centimetres) 
and  multiplying  this  by  the  fraction  represented  by  the  weight  of  the 
animal  (in  kilogrammes)  as  a  numerator,  and  the  weight  of  the 
patient  as  the  denominator,  a  number  is  obtained  which  is  called  the 
toxic  coefficient. 

URINARY   ORGANS. 

Diseases  of  the  Kidney  of  which  Pain  is  a  Prominent 

Symptom. 

The  group  embraces  acute  inflammation  of  the  kidney,  and  those 
painful  affections  classed  under  the  term  nephralgia. 

Acute  Painful  Nephritis. — Acute  inflammation  of  this  kind  is 
not  a  frequent  disease,  indeed,  its  very  existence  is  not  generally  ad- 
mitted ;  it  is  chiefly  observed  in  old  persons  and  in  damp  climates. 
It  may  be  occasioned  by  exposure,  by  direct  violence  to  the  organ,  or 
by  the  irritation  of  a  calculus. 

It  begins  with  a  chill,  soon  followed  by  fever  of  moderate  degree ; 
there  are  nausea  and  vomiting,  and  at  times  diarrhoea  with  tenesmus. 
The  urine  is  voided  drop  by  drop  ;  it  is  red,  and  may  contain  blood.. 
The  patient  complains  of  pain  in  the  renal  region,  sometimes  dull,  at 
other  times  sharp  and  lancinating,  and  augmented  by  pressure  and 
by  moving.  The  pain  is  not  limited  to  the  kidney,  but  radiates  to  the 
diaphragm  and  to  the  bladder.  With  it  are  often  associated  numb- 
ness of  the  thigh  of  the  affected  side  and  retraction  of  the  testicle. 
The  disease  rarely  affects  more  than  one  kidney.  It  lasts  from  one 
to  three  weeks,  and  generally  terminates  in  resolution.  But  it  may 
lead  to  suppuration. 

The  disorder  is  recognized  by  the  pain,  the  fever,  the  retraction  of 
the  testicle,  and  the  appearance  of  the  urine.  It  differs  from  an 
attack  of  colic  by  the  signs  of  disturbance  of  the  urinary  organs,  by 
the  seat  of  the  pain,  and  by  the  fever ;  from  rheumatic  pains  in  the 
back,  by  the  former  of  these  symptoms.  Then,  in  lumbago,  we  rarely 
find  much  febrile  excitement,  nor  are  there  nausea  and  vomiting,  or 
numbness  along  the  course  of  the  anterior  crural  nerve ;  but,  on  the 
other  hand,  the  pain  is  much  more  influenced  by  movements,  espe- 
cially by  stooping,  and  such  other  motions  as  call  the  muscles  of  the 
back  into  play.  Congestion  of  the  kidneys  is  chstinguished  from  in- 
flammation by  its  affecting  both  sides,  by  the  absence  of  protracted  or 
severe  pain,  and  by  the  comparatively  slight  derangement  of  the 
urinary  functions.     Further,  the  congestion  is  not  idiopathic,  and  we 


676  MEDICAL  DIAGNOSIS. 

can  generally  trace  it  to  the  swallowing  of  some  irritating  substance, 
or  to  the  poison  of  a  febrile  malady,  such  as  smallpox  or  typhus. 
From  the  passage  of  a  renal  calculus  acute  painful  nephritis  differs  by 
the  steady,  less  paroxysmal  and  less  violent  pain,  which  does  not,  as 
in  renal  colic,  begin  suddenly  and  end  suddenly ;  by  the  fever ;  and 
by  the  absence  of  a  history  of  previous  attacks. 

Still,  we  must  bear  in  mind  that  a  calculus  may  be  the  cause  of 
the  painful  nephritis.  The  distinction  between  this  form  of  nephritis 
and  that  in  acute  Bright's  disease  will  be  presently  considered. 

Nephralgia. — Severe  pain  in  the  kidney,  unconnected  with  in- 
flammation of  the  organ,  is  ordinarily  caused  by  the  passage  of  a  cal- 
culus. There  is  no  fever,  though  passing  elevations  of  temperature 
may  occur.  Nephralgia  exhibits  a  great  similarity  to  colic ;  but  this 
has  been  already  discussed  ;  and  in  particular  cases  we  are  often  much 
aided  by  the  knowledge  that  in  "renal  colic"  the  patient  has  on  a 
former  occasion  passed  renal  concretions. 

The  amount  of  pain  varies  according  to  the  magnitude  of  the  stone 
and  its  character.  As  a  rule,  calculi  composed  of  oxalate  of  lime  give 
rise  to  most  pain.  We  may  distinguish  them  by  their  roughness  and 
irregularity  and  their  brown  or  dark-gray  color :  those  of  uric  add  and 
iirates  are  reddish  and  much  softer,  and  not  jagged,  and,  unlike  calculi 
consisting  of  the  salts  of  lime,  are  combustible  on  platinum  foil,  leaving 
a  mere  trace  of  residue,  while  the  oxalate  of  lime  calculus  leaves  con- 
siderable residue,  and  is  soluble  in  mineral  acids  without  effervescence. 
Calculi  of  the  mixed  phosphates  are  white,  very  brittle,  soluble  in  acids, 
insoluble  in  alkalies,  and  fuse  in  the  blow-pipe  flame.  The  mixed 
phosphates  rarely  form  a  stone  entirely,  being  often  only  an  incrusta- 
tion around  a  blood-coagulum  or  a  foreign  body,  or  having  a  kernel 
of  uric  acid.  Indeed,  the  majority  of  phosphatic  stones  have  uric  acid 
centres,  while  calculi  of  uric  acid  or  its  salts  possess,  as  a  rule,  the 
same  composition  throughout ;  calculi  of  oxalates  have  often  a  nucleus 
of  uric  acid  and  a  crust  of  phosphates.  Xanthine  and  cystine  are  the 
rarer  constituents  of  stones.  The  former,  like  uric  acid  and  the  am- 
monium and  sodium  urates,  is  consumed  by  heat,  and  burns  without 
visible  flame,  but  the  murexide  test  exhibits  an  orange-yellow  color ; 
cystine  burns  with  a  bluish-white  flame  emitting  an  odor  like  that  of 
burning  fat,  and  the  powder  is  soluble  in  dilute  ammonia.  The  crys- 
tallization of  the  ingredients  of  the  urine  forming  a  calculus  is  very 
apt  to  take  place  around  particles  of  mucus. 

As  already  stated,  we  have  in  the  severity  of  the  pain  a  sign  in- 
dicative of  the  nature  of  the  case.  Still,  there  are  states  in  which 
paroxysms  of  'pa,in  referred   to  the   neighborhood  of  the  kidney  are 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     677 

attributable  to  other  causes  than  the  passage  of  a  calculus.  Leaving 
out  of  consideration  that  doubtful  disease,  pure  neuralgia  of  the  kidney, 
we  find  a  few  affections — very  rare,  it  is  true — which  closely  simulate 
the  passage  of  a  renal  calculus. 

The  first  of  these  is  the  pain  occasioned  by  an  inflamed  and  idcei- 
ated  ureter.  Todd  relates  a  case  of  the  kind.^  The  patient  had  severe 
attacks  of  lancinating  pain,  referred  to  the  right  side,  lasting  for  weeks, 
and  accompanied  by  constant  and  intractable  vomiting.  The  urine 
contained  pus  in  varying  quantity,  but  neither  blood  nor  calculous 
matter  could  be  detected.  At  one  time  he  continued  free  from  any 
paroxysm  for  four  years.  After  death  the  most  careful  search  was 
made  for  a  calculus,  but  none  could  be  discovered.  The  ureter  of 
the  right  side  was  thickened  throughout  the  greater  part  of  its  course, 
and  deposits  of  lymph  adhered  to  its  mucous  membrane.  A  some- 
what similar  train  of  phenomena  may  occur  from  irritation  or  inflam- 
mation of  the  ureter  caused  by  the  poison  of  rheumatism  or  gout, 
although  the  paroxysms  of  pain  are  apt  to  be  neither  so  severe  nor  of 
so  long  duration. 

Another  morbid  condition  closely  resembling  the  passage  of  a  renal 
calculus  may  result  from  malarial  jwison.  How  close  this  resemblance 
may  be,  the  following  case  will  show : 

A  soldier,  twenty-four  years  of  age,  of  strong  constitution,  was 
seized  suddenly  with  pain  over  the  left  kidney.  The  loin  was  sensi- 
tive to  the  touch,  and  appeared  swollen.  The  skin  was  hot ;  the 
pulse  100.  The  urine  was  reddish,  but  was  not  found  to  be  abnor- 
mal. The  pain  continued  for  several  days,  becoming  more  severe, 
notwithstanding  that  by  direction  of  Dr.  Hilborne  West,  with  whom  I 
saw  the  man,  six  ounces  of  blood  were  drawn  from  near  the  affected 
part.  On  the  fourth  day  of  the  disorder  he  was  assailed  with  excru- 
ciating pain  along  the  course  of  the  ureter,  attended  with  the  voiding, 
at  short  intervals,  of  a  high-colored  urine.  The  attack  lasted  from  six 
o'clock  in  the  evening  until  five  o'clock  the  next  morning,  leaving  him 
exhausted ;  the  only  relief  throughout  its  duration  being  obtained 
from  the  inhalation  of  chloroform.  At  six  o'clock  that  evening  an- 
other seizure,  of  equal  violence,  set  in  ;  and,  after  the  lapse  of  twenty- 
four  hours,  again  another.  Seeing  the  recurrence  of  the  paroxysms 
at  about  the  same  time  of  each  day,  and  learning  from  the  patient 
that  a  few  months  before  he  had  had  a  remittent  fever,  which  had 
left  behind  an  irregular  intermittent,  we  resolved  upon  the  adminis- 
tration of  large  doses  of  sulphate  of  quinine  in  the  interval  between 

^  Clinical  Lectures,  Lecture  IL,  on  Diseases  of  the  Urinary  Organs. 


678  MEDICAL  DIAGNOSIS. 

the  paroxysms.  The  seizure  did  not  take  place  that  night ;  but,  the 
remedy  being  a  day  or  two  afterwards  suspended,  the  fourth  night 
was  again  a  night  of  anguish.  The  antiperiodic  was  resumed,  and 
continued,  in  lessened  doses,  for  three  weeks.  The  patient  remained 
under  observation  for  about  six  weeks  after  the  last  attack,  gradually 
recovering  his  health  and  spirits.  When  he  was  lost  sight  of,  there 
was  still  a  dull  pain  in  the  left  lumbar  region,  with  inability  to  stand 
erect ;  but  no  return  of  the  excruciating  intermittent  pains. 

In  a  case  of  this  kind,  which  was  observed  before  the  days  of 
Laveran's  discovery,  it  is  evident  that  nothing  but  a  knowledge  of  the 
history  of  the  patient,  and  the  noting  of  the  regularly  recurring  onsets 
of  the  pain,  could  have  led  to  a  correct  appreciation  of  its  cause.  We 
sometimes  meet  with  a  so-called  neuralgia  of  the  bladder,  of  similar 
origin,  and  having  much  the  same  symptoms,  except  that  the  distress- 
ing pain  is  referred  to  the  bladder.  As  in  the  case  just  detailed,  the 
attacks  occur  at  night. 

These  remarks  are  all  based  on  the  assumption  that  the  renal  pain 
is  very  severe  and  paroxysmal  in  its  character.  Let  us  now  briefly 
inquire  into  the  significance  of  a  steady  and  less  acute  pain,  premising- 
that  we  have  excluded  from  consideration  abdominal  aneurism,  affec- 
tions of  the  muscles  of  the  back,  of  the  spine,  and  of  the  tissues  sur- 
rounding the  kidney,  in  which  diagnosis,  of  course,  we  are  materially 
assisted  by  an  examination  of  the  urine. 

We  meet  with  persistent  jyain  referable  to  the  kidney  itself,  in  in- 
flammation of  the  organ,  especially  in  that  variety  of  inflammation 
affecting  the  infundibula  and  pelvis,  termed  pyelitis.  We  also  en- 
counter it  in  malignant  disease  of  the  kidney  ;  sometimes,  although  it 
is  not  then  of  long  duration,  from  the  irritation  of  concentrated  and 
highly  acid  urine ;  much  more  generally  from  the  presence  of  a  stone 
lodged  in  the  kidney.  The  pain  in  the  latter  complaint  often  extends 
along  the  course  of  the  ureter  to  the  testicle,  which  is  retracted  and 
swollen.  Not  infrequently  there  is  also  tenderness  on  pressure  over 
the  affected  kidney,  and  the  pain  is  greatly  mcreased  by  active  exer- 
cise ;  and  it  is  not  uncommon  to  find,  associated  with  these  exacer- 
bations of  pain,  nausea  and  vomiting,  and  the  appearance  of  blood 
in  the  urine. 

There  is  yet  another  point  in  the  diagnosis  of  the  passage  of  calculi 
which  we  must  not  overlook, — namely,  that  the  pain  may  be  referred 
to  other  parts  than  the  region  of  the  kidney  and  the  course  of  the 
ureter.  It  may  be  felt  near  or  at  the  sacrum,  and  not  merely  on  one 
side ;  it  may  extend  to  the  bladder  and  become  associated  with  a 
painful  spasm  of  this  viscus  and  with  the  voiding  of  urine  drop  by 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     679 

drop ;  or  to  the  testicle,  which  becomes  sensitive  and  swells ;  or  to 
the  thigh,  which  feels  numb  ;  or  it  may  be  referred  to  the  region  of 
the  appendix,  or  to  the  right  hypochondrium,  and  extend  downward, 
but  not  be  perceived  in  the  loin.  Under  the  latter  circumstances 
there  may  be,  with  pain  of  great  intensity,  coexisting  distention  of 
the  colon,  vomiting,  and  constipated  bowels,  and  the  symptoms  so 
closely  resemble  those  of  the  passage  of  a  biliary  calculus  that  only 
the  detection  of  blood  in  the  urine  prevents  error/  Again,  as  hap- 
pened in  two  cases  which  came  under  my  notice,  the  pain  may  be 
referred  to  the  left  hypochondrium  or  along  the  course  of  the  colon, 
may  be  associated  with  soreness  to  the  touch  and  with  digestive  dis- 
orders, and  may  closely  simulate  an  organic  lesion  of  the  stomach  or 
intestine.  Nothing  but  careful  and  repeated  examinations  of  the  urine^ 
and  observing  the  irregular  and  whimsical  course  the  supposed  intes- 
tinal malady  pursues,  will  enable  us  to  arrive  at  a  knowledge  of  the 
truth. 

Nor  must  we  be  unmindful  that  a  calculus  may  be  months  in 
passing,  and  that  as  it  changes  its  position  the  seat  of  the  pain 
changes.  I  had  a  case  of  the  kind  under  my  charge  in  a  lady  about 
fifty  years  of  age.  She  suffered  for  weeks  at  a  time  from  excruci- 
ating pains,  beginning  in  the  left  kidney,  then  felt  somewhat  below  it^ 
and  finally  localized  in  the  neighborhood  of  the  left  ovary.  She  was 
occasionally  free  from  pain  for  five  or  six  days.  But  it  was  only  after 
fully  nine  months  of  recurring  suffering  that  the  passage  of  a  calcu- 
lus the  size  of  a  plum-stone,  followed  by  a  discharge  of  large  amounts 
of  a  gritty  substance  and  a  soapy-looking  urine,  removed  her  distress. 
The  stone  consisted  of  urates. 

The  symptoms  of  renal  calculus  may,  after  having  existed  for  a 
longer  or  shorter  time,  entirely  cease,  owing  to  the  calculus  becoming- 
encysted  and  thus  remaining  innocuous  ;  or  to  its  obstructing  the 
ureter,  causing  retention  of  the  urine,  and,  by  pressure,  producing 
gradual  atrophy  of  the  cortical  and  tubular  structures,  the  kidney 
being  finally  converted  into  a  mere  bag. 

In  concluding  the  subject,  it  will  be  useful  to  group  together  the 
signs  by  which  we  may  infer  the  existence  of  a  calculus  in  the  Mdney. 
They  are :  frequent  micturition,  .often  attended  with  pain  at  the  end 
of  the  penis ;  pain  in  the  loin  on  one  side,  with  or  without  accompa- 
nying soreness,  occasionally  passing  suddenly  into  a  violent  parox- 
ysm, with  a  tendency  to  shoot  along  the  course  of  the  ureter  to  the 
testicle  and  the  hip  of  the  aching  side  ;  and  in  some  cases  the  dis- 

^  Case  of  Owen  Rees,  Guy's  Hospital  Reports,  3cl  Series,  vol.  x. 


^80  MEDICAL  DIAGNOSIS. 

charge  of  pus  due  to  coincident  pyelitis.  These  symptoms  become 
positive  evidence  if  the  blood-extractives  be  present  in  the  patient's 
urine,  or  if  this,  when  examined  microscopically,  be  found  to  contain 
blood-corpuscles  ;  or  if  we  know  that  attacks  of  haematuria  have  pre- 
viously happened,  and  that  gravel  or  small  urinary  concretions  have 
at  any  time  been  discharged.  The  presence,  too,  of  microscopic  cal- 
culi in  the  urine,  points  to  the  existence  of  larger  concretions  in  the 
pehis  or  in  the  structure  of  the  kidney.  But  all  these  indications  are 
far  from  being  always  present.  The  renal  stones  may  be  so  large  that 
they  cannot  leave  the  kidney ;  we  may  have  nothing  but  the  symp- 
toms of  a  pyelitis,  which  we  suspect  to  be  calculous,  and  even  these 
symptoms  may  be  wanting.  To  determine  whether  both  kidneys 
■Sire  implicated  in  the  calculous  disease,  which  occurs  in  about  fifteen 
per  cent,  of  the  cases ,^  we  must  examine  the  urine  during  the  passage 
of  a  renal  calculus.  If  the  urine  become  perfectly  healthy,  when 
previously  it  has  been  abnormal,  we  conclude  that  it  comes  from  a 
healthy  kidney,  and  that  the  secretion  from  the  diseased  one  is  tempo- 
rarily blocked  up.  Another  method  of  determining  which  kidney  is 
diseased  is  by  catheterization  of  the  ureters,  and  the  examination  of 
the  urine  thus  obtained  from  each.  But  this  is  a  very  difficult  pro- 
cedure, and  is  only  possible  in  the  hands  of  a  surgical  or  gynaecologi- 
cal expert.  Yet  another  method  that  has  been  suggested  is  by  press- 
ure on  the  pelvis,  and  the  ingenious  apparatus  invented  by  Harris.^ 
But  the  most  certain  of  all  our  means  is  by  the  X-ray,  and  I  add  a 
reproduction  of  a  skiagraph  taken  by  Dr.  Leonard  from  a  patient  in 
whom  the  calculus  thus  detected  was  removed  by  Dr.  Keen.  I  have 
.also  seen  a  stone  in  the  ureter  brought  to  light  by  the  same  process. 
Irrespective  of  finding  the  stone,  the  Roentgen  rays  enable  us  to  do 
what  no  other  process  can  accomplish, — to  detect  the  presence  of 
several  stones  in  the  same  kidney,  and  to  determine  their  relative  size 
and  position.^ 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine, 
associated  with  more  or  less  Dropsy. 

The  chief  of  these  diseases  is  Bright's  disease.  At  the  present 
day  we  hold  that  the  disease  which  bears  Bright's  name  consists  of  a 
;gT0up  of  maladies  having  the  common  feature  of  a  more  or  less  albu- 
minous state  of  the  urine.     But,  though  I  beheve  this  view  to  be  the 

^  Henry  Morris,  AUbutt's  System  of  Medicine,  vol.  iv. 
^  Journ.  Amer.  Med.  Assoc,  Jan.  29,  1898. 
»  Leonard,  Phila.  Med.  Journ.,  Aug.  20,  1898. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     681 

correct  one,  I  shall  in  this  sketch  prefer  to  consider  the  disorder  in  the 
main  as  it  is  seen  separated  by  broadly  drawn  lines  into  an  acute  and 
a  chronic  form,  and  then  examine  the  further  differences  these  present. 
Anatomically  speaking,  we  have  a  diffuse  nephritis  which  is  paren- 
chymatous or  interstitial ;  interstitial  nephritis,  generally  seen  in  a 
chronic  form,  and  often  the  result  of  gradual  insidious  tissue  changes- 
of  a  degenerative  kind ;  the  waxy  or  lardaceous  kidney,  and  the  fatty 
kidney,  which  is  mostly  an  attendant  upon  other  kidney  alterations. 

Acute  Bright's  Disease. — In  this  form,  which  is  almost  always 
an  acute  parenchymatous  nephritis,  the  symptoms  are  of  an  acute 
character.     Especially  so  is  the  dropsy,  which  is  quickly  developed 

Fig.  64. 


Epithelial  casts  and  epithelial  cells  from  the  kidneys  found  in  a  case  of  acute  Bright's  disease  (acute 
parenchymatous  nephritis)  ;  magnified  about  460  diameters. 


and  soon  becomes  the  most  marked  token  of  the  malady.  The  his- 
tory of  a  large  number  of  cases  is  as  follows.  After  exposure  to  wet 
or  cold  and  checked  perspiration,  a  fever  sets  in,  accompanied  by 
nausea,  and  by  a  dull  pain  in  the  region  of  both  kidneys,  extending 
along  the  ureters.  The  eyelids  and  face  become  puffy  and  swollen, 
and  soon  a  general  oedematous  condition  of  the  skin  is  observable, 
showing  itself  very  plainly  in  the  extremities,  scrotum,  and  abdominal 
parietes.  Subsequently  dropsical  effusions  often  take  place  into  the 
interior  cavities. 

The  same  symptoms  are  noticed  in  the  acute  parenchymatous 
nephritis,  which  so  constantly  attends  scarlatina,  except  that,  following 
as  it  does  an  exhaustive  disease,  there  are  from  the  onset  much  greater 
pallor  and  general  debility.  Acute  parenchymatous  nephritis  is  also 
met  with,  though  less  frequently,  and  generally  in  a  less  violent  form. 


682  MEDICAL  DIAGNOSIS. 

in  other  infectious  diseases,  as  in  smallpox,  measles,  diphtheria,  typhoid 
fever,  typhus.  It  occurs  also  in  malaria  and  yellow  fever.  It  may 
follow  hard  drinking,  a  lightning-stroke,^  or  sewer-gas  poisoning.^ 

The  urine  in  the  acute  malady  is  of  high  specific  gravity,  and  may 
be  dingy  from  its  admixture  with  blood.  There  is  a  frequent  desire 
to  void  it,  although  the  whole  quantity  passed  is  rather  below  the 
natural  average.  The  urine  contains  a  large  amount  of  albumin ;  a 
microscopical  examination  brings  to  light  red  blood-cells  and  casts, 
lined  here  and  there  with  blood-corpuscles.  As  the  malady  pro- 
gresses, these  "blood-casts"  disappear,  and  we  find  casts  coated  with 
epithelium,  which  may  be  normal  or  slightly  fatty,  and  with  free  nuclei ; 
or  we  observe  granular  or  hyaline  casts  ;  or  we  may  discern  leucocytes 
and  long  cylindrical  ribbon-like  mucous  casts.  Furthermore,  crystals 
of  uric  acid,  of  urates,  even  of  oxalates,  and  a  considerable  amount 
of  renal  epithehum,  are  often  seen  in  the  sediment.  The  chlorides 
and  phosphates  are  diminished ;  the  uric  acid  is  less  so,  may,  indeed, 
like  the  pigments,  be  increased.  The  amount  of  urea  fluctuates  much  : 
it  is  generally  lessened. 

There  is  moderate  fever,  with  a  temperature  of  about  101°;  the 
pulse,  however,  may  be  quick,  tense,  and  full.  The  skin  is  generally 
harsh  and  dry  ;  nausea  and  vomiting  are  of  common  occurrence. 

The  urgent  symptoms  last  ordinarily  for  several  weeks,  and  the 
albumin  gradually  disappears.  But  this  is  not  the  invariable  issue ; 
the  disease  may  gradually  lapse  into  a  chronic  form.  Or  a  certain 
amount  of  albumin  may  remain  in  the  urine ;  and  after  exposure  this 
increases,  and  the  dropsy  and  most  of  the  acute  symptoms  return.  In 
some  instances  of  the  malady,  not  in  many,  there  are  numerous  tube- 
casts  and  free  epithelium  in  the  urine,  but  little  albumin ;  and,  on  the 
other  hand,  in  acute  interstitial  nephritis,  with  scanty,  highly  albu- 
minous urine  and  marked  general  dropsy,  tube-casts  may  be  absent 
from  first  to  last.^ 

There  is  a  form  of  acute  Bright's  disease  due  to  a  bacillus.  Letz- 
erich *  describes  it  as  "nephritis  bacillosa  interstitialis  primaria."  It 
occurs  in  children,  runs  its  course  with  a  moderate  fever  in  from  two 
to  six  weeks,  and  generally  ends  in  recovery.  The  urine  contains  red 
blood-corpuscles,  a  few  leucocytes,  only  small  amounts  of  albumin, 
but  great  numbers  of  bacilli,  shorter  and  thicker  than  the  tubercle 

^  Medical  and  Surgical  Reporter,  July  23,  1887. 

'■'  Lancet,  March,  1894. 

^  Dickinson,  Allbutt's  System  of  Medicine,  vol.  iv.  p.  369. 

*  Neurol.  CentralbL,  1887,  quoted  in  Sajous's  Annual,  1888,  p.  483. 


THE   URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     683 

bacilli,  and  easily-stained  with  methyl-violet.     An  infectious  nephritis 
also  has  been  described  due  to  the  bacillus  coli  communis.'^ 

Whatever  the  attending  circumstances,  the  risk  to  life,  when  an 
attack  of  acute  Bright's  disease  has  been  prolonged,  is  greatly  in- 
creased by  the  supervention  of  local  inflammations, — as  of  the  pleura, 
lungs,  peritoneum,  or  pericardium ;  or  by  the  sudden  effusion  of  fluid 
into  the  pulmonary  structure  ;  or  by  the  retention  of  urea  in  the  blood 
and  consequent  uraemic  intoxication. 

The  recognition  of  the  disease  is  readily  effected.  The  puffy,  pale 
face ;  the  general  dropsy ;  the  albumin  in  the  urine,  associated  with 
tube-casts, — form  a  combination  of  signs  so  remarkable  that  it  is 
difficult  to  mistake  their  meaning.  Many  of  the  same  phenomena  are 
encountered  in  the  chronic  form  of  the  malady ;  therefore,  what  is 
about  to  be  said  of  the  differential  diagnosis  of  the  acute  complaint 
may  be  in  the  main  applied  with  almost  equal  correctness  to  the 
chronic  ailment. 

The  chief  disorders  with  which  acute  Bright's  disease  is  apt  to  be 
confounded  are : 

Acute  Painful  Nephritis  ; 

Suppurative  Nephritis  ;  Purulent  Urine  ; 

hematuria  ; 

Simple  Albuminuria  ; 

Pulmonary  (Edema  ; 

Pleurisy  and  Pericarditis  ; 

Dropsy  ; 

Coma  ;  Convulsions. 

Acute  Painful  Nephritis. — This  differs  from  acute  Bright's  disease 
by  its  affecting  generally  only  one  kidney,  by  the  much  greater  pain 
and  tenderness  in  the  lumbar  region,  by  the  retraction  of  the  testicle, 
and  by  the  higher  degree  of  febrile  excitement.  Then,  too,  the  deeply 
colored  urine  which  is  voided  contains  little  or  no  albumin. 

Suppurative  Nephritis ;  Purulent  Urine. — In  rare  cases  the  suppu- 
rative process  may  coexist  with  Bright's  disease.  But,  on  the  whole, 
the  two  disorders  are  distinct  and  may  be  readily  discriminated.  We 
find  pus  of  renal  origin  in  the  urine,  in  consequence  of  pyelitis  or  of 
abscess  of  the  kidney.  The  former  is  generally  linked  to  the  irritation 
of  calculi,  or  is  an  infective  process  ;  the  latter  shows  a  fever  of  a 
remittent  type,  and  often  a  well-defined  swelling  is  felt  in  the  lumbar 
region  and  extending  far  downward.*  All  this  is  different  from  Bright's 
disease.     Then,  we  detect  pus  as  well  as  blood  in  the  urine  of  cases 

1  Fernet  et  Papillon,  Bull,  et  Mem.  de  la  Soc.  Med.  des  Hop.,  1892. 


g84  MEDICAL   DIAGNOSIS. 

of  pyelitis  or  of  renal  abscess,  and  any  casts  that  are  found  are  apt 
to  be  covered  with  leucocytes,  which  is  of  very  rare  occurrence  in 
acute  Bright's  disease. 

Hcematuria. — In  hsematuria,  if  we  can  speak  of  it  as  a  separate 
disease,  there  is  albumin  in  the  urine ;  and,  on  the  other  hand,  some 
blood  as  well  as  pus  may  be  present  in  the  urine  of  Bright's  disease. 
But,  as  in  purulent  urine,  the  quantity  of  albumin  met  with  in  hsema- 
turia  is  small ;  in  fact,  it  is  in  exact  proportion  to  the  amount  of  blood 
or  pus  the  urine  contains  ;  whereas,  on  the  contrary,  if  the  secretion 
from  a  Bright's  kidney  be  mixed  with  pus  or  blood,  the  amount  of 
albumin  is  generally  large.     The  microscopic  examination,  too,  and 
the  casts  found,  and  their  predominating  character,  are  of  great  value. 
Simple  Albuminuria. — By  this  is  meant  an  albuminous  urine  un- 
connected with  any  marked   structural   lesion,  except  congestion, — 
such  an  albuminuria  as  is  observed  as  a  transient  phenomenon  in  the 
course  of  several  diseases ;  as   in   the   exanthemata,  in   typhoid,  in 
typhus,  in  cholera,  in  hectic  fever,  in  chronic  congestion  of  the  liver,, 
in  oxaluria,  or  as  a  consequence  of  surgical  diseases  and  operations, 
and  of  ether  narcosis.     An  albuminuria  of  similar  kind  is  met  with 
when   the   kidneys    become    congested   from   interference   with   the 
circulation,  as  in  disease  of  the  heart,  or  from   the  pressure  of  a 
gravid  womb.     Albumin  in  the  urine  may  also  be  encountered  in 
erysipelas,  in  diphtheria,  in  pneumonia,  in  acute  rheumatism  and  in 
gout,  consecutively  to  very  high  temperatures,  to  a  burn,  to  a  blister 
or  a  large  mustard-plaster,  or  to  the  use  of  salicylic  acid  or  of  turpen- 
tine or  of  carbolic  acid.     But  in  all  these  conditions  the  quantity  found 
is  small  and  transitory,  very  unlike  what  it  is  in  the  persistent  albu- 
minuria of  Bright's  disease,  and  the  urine  is  usually  dense  and  high- 
colored.     Then  the  constitutional  symptoms  and  the  general  clinical 
features  in  the  morbid  states  referred  to  tell  us  the  meaning  of  the 
albuminuria.     Moreover,  there  is  really  often  more  than  mere  conges- 
tion ;  there  is  present  a  parenchymatous  inflammation  to  a  limited 
degree,  and  of  a  transitory  kind.     In  all  these  cases  of  albuminuria 
the  amount  of  albumin  is  apt  to  be  small,  and  there  are  few,  if  any, 
casts.     When  found,  these  are  generally  of  the  epithelial  or  hyaline 
variety,  and  are  not  highly  granular  or  fatty. 

In  addition  to  these  forms  of  simple  albuminuria  there  is  one  of 
great  importance  to  recognize,  where  the  albumin  happens  in  persons 
Avho  in  every  respect  seem  healthy,  and  occurs  shortly  after  partaking 
plentifully  of  food,  especially  of  albuminous  food,  or  after  severe  exer- 
cise, particularly  in  young  persons  at  or  near  the  age  of  puberty.  Some 
of  these  cases  are  cyclic,  occurring  only  at  certain  times  of  the  day ;, 


THE  UEINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     685 

in  much  fewer,  the  albuminuria  is  persistant.  In  the  great  majority  of 
cases  there  is  a  time  in  every  day  in  which  the  urine  is  free  from  albu- 
min. It  is  normal  in  quantity,  normal  or  slightly  increased  in  specific 
gravity,  normal  in  the  amount  of  urea  it  contains,  and  no  tube-casts 
are  found  in  its  sediment.  The  amount  of  albumin  in  these  functional 
albuminurias  is  small,  and  there  are  no  cardio-vascular  changes ;  in- 
deed, there  is  no  symptom  except  the  albuminuria  to  suggest  disease. 
This  kind  of  albuminuria  has  a  strong  bearing  on  life  assurance. 

There  is  a  form  of  albuminuria  that  stands  in  close  connection 
with  excessive  uric  acid  formation  and  oxaluria,  to  which  I  have  called 
attention.^  The  amount  of  albumin  is  generally  small ;  hyaline  and 
epithelial  casts  are  found,  though  they  are  scanty.  The  specific  gravity 
of  the  urine  is  high,  and  this,  as  well  as  urates  or  the  oxalates  in  the 
urine,  is  of  much  significance.  Violent  exercise  increases  this  albumi- 
nuria of  uric  acid  and  oxaluria.  The  cases  may  be  of  short  or  long 
duration  ;  recovery  is  the  rule. 

In  elderly  people,  we  meet  with  a  form  of  albuminuria  in  which 
there  are  traces  of  albumin  in  the  urine,  and  hyaline  and  finely  gran- 
ular casts  of  small  diameter.  The  specific  gravity  of  the  urine  is 
normal,  the  general  health  is  unimpaired.  If  this  albuminuria  be  due 
to  beginning  senile  changes,  they  are  very  slow  in  their  development, 
and  my  experience  leads  me  to  the  conclusion  reached  by  the  inves- 
tigations of  F.  C.  Shattuck,  that  it  is  of  little  practical  importance. 

Pulmonary  (Edema. — Bright's  disease  is  one  of  the  most  frequent 
causes  of  dropsical  effusion  into  the  air-cells  ;  oppression  in  breathing, 
inability  to  lie  in  the  recumbent  position,  cough,  frothy  expectoration, 
are  the  symptoms.  And  to  distinguish  this  oedema  from  that  produced 
by  other  morbid  states  we  have  only  to  examine  the  urine  carefully. 
Yet  we  must  not  forget  that  small  amounts  of  albumin  may  be  found 
in  the  urine  from  any  stress  of  breathing,  and  from  diseases  that,  like 
those  of  the  heart,  congest  the  lungs  and  kidney  and  are  themselves 
among  the  causes  of  pulmonary  oedema. 

Pleurisy  and  Pericarditis. — The  tendency  to  inflammations  of  the 
serous  membranes  is  a  remarkable  peculiarity  of  Bright's  disease. 
We  may  discriminate  pleurisy  or  pericarditis  complicating  the  malady 
from  either  of  these  affections  of  other  origin,  by  noting  the  far  greater 
amount  of  dropsy  that  is  found  in  these  disorders,  and  by  detecting 
persisting  albumin  and  tube-casts-  in  the  urine. 

Dropsy. — By  an  examination  of  the  urine,  too,  may  be  distin- 
guished the  dropsy  of  the  complaint  under  consideration  from  that 

1  Amer.  Journ.  Med.  Sci.,  Jan.  1893. 
A?, 


686  MEDICAL   DIAGNOSIS. 

produced  by  other  causes.  "And  we  also  see  often  the  evidences  of 
the  true  nature  of  the  dropsy  in  its  beginning  with  swelHng  of  the 
face,  and  in  the  characteristic  physiognomy  which  it  has  a  share  in 
developing. 

Coma;  Convulsions. — A  dangerous  complication  of  Briglit's  disease 
manifests  itself  by  drowsiness  and  convulsions.  Now,  it  is  very  mi- 
portant  to  distinguish  the  cases  produced  by  uraemic  poisoning  from 
epileptiform  convulsions  and  kindred  states  in  which  there  is  no  appre- 
ciable change  of  structure  in  the  kidneys.     Let  us  see  how  they  differ. 

Urcemia,  or  uraemic  intoxication,  is  commonly  preceded  by  a  dimi- 
nution in  the  urinary  secretion.  In  some  cases  the  marked  phenomena 
set  in  mth  a  chill.  There  is  headache,  with  indistinct  vision,  great 
drowsiness,  and  vertiginous  sensations  ;  the  pupils  are  sluggish  and 
usually  dilated ;  the  hearing  is  impaired ;  the  countenance  is  dusky ; 
the  skin  is  cool,  with  short  rises  of  febrile  heat :  and  the  patient  suf- 
fers from  constipation,  nausea,  and  obstinate  vomiting.  Ansesthesia 
and  various  kinds  of  cutaneous  eruptions  may  be  observed.  The  dul- 
ness  of  mind  is  apt  to  deepen  into  stupor  or  coma,  or  convulsions  set 
in  as  precursors  of  the  coma,  which  terminates  in  death  unless  the 
urinary  secretion  be  freely  re-established.  The  coma  may  at  one  time 
be  so  profound  that  it  is  impossible  to  arouse  the  patient,  whilst  at 
another  time  he  rouses  himself  and  acts  with  intelligence.  The  con- 
vulsions generally  succeed  one  another  rapidly. 

As  regards  the  decided  lessening,  or  suppression,  of  the  urinary 
secretion,  though  this  is  the  rule,  it  is  not  constant.  I  have  known 
the  symptoms  of  uraemia  many  a  time  to  receive  an  erroneous  inter- 
pretation, from  supposing  that  uraemia  could  not  exist,  as  the  quan- 
tity of  urine  passed  was  about  normal.  We  must  test  for  urea  and 
the  other  urinary  ingredients,  which  may  be  profoundly  changed  in 
amount,  notwithstanding  the  seemingly  healthy  aspect  of  the  secretion, 
and  notwithstanding,  too,  that  it  may  be  found  free  from  albumin.  In 
addition  to  the  great  decrease  in  the  urea,  the  uric  acid  is  reduced ;  the 
specific  gravity  is  generally  low ;  casts  are  mostly  found  in  the  urine. 

Cases  of  uraemic  coma  differ  from  ordinary  comatose  conditions,  as 
mtnessed  in  apoplexy,  in  fevers  of  a  .low  type,  or  following  narcotic 
poisoning,  by  the  dissimilar  symptoms  ushering  them  in.  The  coma 
is  much  more  suddenly  developed  than  that  in  fevers  ;  far  less  sud- 
denly than  that  of  apoplexy  or  narcotic  poisoning.^     Then,  the  stertor- 

^  There  may  however,  be  exceptions  to  this  rule,  as  in  the  case  reported  in' 
Moore  in  the  London  Medical  Gazette,  1845,  in  which  a  person  liecame  comatose 
after  taking  laudanum,  yet  his  death  was  found  to  be  caused  by  contracted  kidneys. 


THE  URINE,  AND  DISEASES  OF  THE   URINARY  ORGANS.     687 

ous  respiration  is  peculiar:^  the  loud  sounds  of  the  expired  air  are  of 
much  higher  key,  not  hke  the  low,  guttural  tones  of  apoplexy.  Fur- 
thermore, we  may  have  in  the  general  dropsy  a  clue  to  the  nature  of 
the  case  ;  but  of  course  the  most  certain  light  is  thrown  on  it  by  tlie 
analysis  of  the  urine. 

The  same  remarks  apply  to  the  delirium  or  to  the  epileptiform 
convulsions  of  uraemia.  Here  the  difficulty  in  diagnosis  is  increased 
by  the  first  seizure  often  happening  unexpectedly, — so  much,  in  truth, 
increased,  that,  unless  Ave  are  aware  of  the  history  of  our  patient  and 
have  previously  examined  the  urine,  the  true  explanation  of  the  symp- 
toms is  not  to  be  reached.  Urmmic  delirium  is  rare,  but  I  have  met 
with  it  under  circumstances  in  which  nothing  preceded  it  to  indicate 
its  nature.^  Cases  of  acute  urcemio  mania  may  also  originate  thus  sud- 
denly. Cases  of  urcemic  convulsions  may  occur  in  pregnant  women ; 
in  them,  however,  the  tendency  to  disorder  of  the  kidney  is  so  great 
that  we  are  rarely  in  error  in  concluding  convulsions  to  be  of  uraemia 
origin.  We  must,  however,  here,  as  in  all  convulsions,  be  certain 
that  we  do  not  mistake  effect  for  cause.  A  slight  amount  of  albumin 
may  follow  violent  convulsions  in  epileptic  seizures.  The  temjDerature 
in  urEemic  convulsions  is  variable.  It  is  generally  stated  to  be  low ; 
but  this  is  denied  by  Bartels,  who  notes  it  as  considerably  elevated,-'' 
and  by  McBride,^  and  by  Hughes.^  Among  the  other  marked  nervous 
manifestations  of  uraemia  may  be  persistent  headache,  anaesthesia, 
temporary  blindness,  and  palsies  of  uraemic  origin,  local  or  hemiplegic, 
without  gross  lesion  in  the  brain. 

Uraemia  is  sometimes  a  chronic  state,  more  particularly  in  chronic 
interstitial  nephritis.  Any  of  the  symptoms  already  described  may  be 
met  with ;  very  common  are  nausea,  vomiting,  dyspnoea,  headache, 
and  eye  disturbances.  Convulsions,  too,  epileptic  in  character,  and 
either  general  or  of  Jacksonian  type,  are  found,  and  in  some  cases 
stomatitis,  in  others  a  long-continued,  though  moderate,  fever,  often 
with  considerable  mental  torpor. 

The  cause  of  uraemia  is  still  undetermined  :  a  contamination  of  the 
blood  by  retained  poisonous  urinary  ingredients  or  poisonous  sub- 
stances that  have  formed  from  them  always  hap]jens,  thougli  these 
toxines  mav  be  of  different  kinds. 


^  Addison,  Guy's  Hospital  Reports,  ISoO. 

^  Case  at  the  Pennsylvania  Hiisjiiliil,  April.  18(55. 

•'  Ziemssen's  Cyclopiedia. 

■*  American  Journal  of  Neuroloi^'y,  188.">. 

■'  PhihKJelpliia  Hospital  Reports,  1  81t;3. 


688  MEDICAL  DIAGNOSIS. 

Chronic  Bright's  Disease. — An  acute  attack  of  Blight's  disease 
may  gradually  pass  into  a  confirmed  malady,  or  the  complaint  may 
come  on  insidiously  and  develop  itself  slowly. 

The  transition  from  the  acute  to  the  chronic  disease  is  indicated 
by  the  disappearance  of  blood  from  the  urine,  by  its  lessened  specific 
gravity  and  the  smaller  amount  of  albumin  it  contains,  by  the  temper- 
ature becoming  normal,  and  not  uncommonly  by  a  temporary  diminu- 
tion of  the  anasarca  and  an  increase  in  the  quantity  of  urine  voided. 
When  the  disease  runs  a  more  or  less  chronic  course  from  the  begin- 
ning, its  initiatory  steps  are  obscure.  We  generally  find  such  cases  m 
persons  who  are  poorly  fed  and  half  clad,  who  live  in  damp,  ill-ven- 
tilated houses,  who  are  intemperate,  or  who  have  been  subject  to 
great  grief  or  worry,  or  are  saturated  with  malaria,  or  whose  con- 
stitutions are  ruined  by  syphilis  or  by  scrofula,  or  who  show  signs  of 
arteriosclerosis.  The  first  symptoms  noticed  may  be  frequent  desire 
to  urinate ;  swelling  of  the  extremities  or  of  the  face ;  increasmg 
pallor  and  general  debility ;  and  headache,  especially  occipital  head- 
ache. An  examination  of  the  urine  reveals  at  once  the  cause  of  the 
protracted  indisposition.  Yet  the  renal  disease  may  lead  suddenly  to 
a  fatal  termination  without  the  patient  having  experienced  any  ill 
health.  And  even  after  the  malady  has  been  recognized,  it  is  difficult 
to  predict  its  course.  We  meet  in  many  cases  with  the  same  phe- 
nomena as  those  of  the  acute  variety,  except  the  fever.  But  in 
others  the  signs,  are  dissimilar, — the  dropsy,  for  instance,  is  slight  or 
is  wholly  wanting.  The  only  constant  and  characteristic  manifesta- 
tions are  the  increasing  anaemia,  and  the  presence  of  albumin  and 
tube-casts  in  the  urine. 

Where  chronic  nephritis  is  suspected  the  urine  passed  at  different 
times  of  the  day,  especially  the  morning  and  evening  urme,  should 
be  separately  examined.  Generally,  the  urine  is  of  unchanged  spe- 
cific gravity,  though  this  is  lowered  as  the  urinary  solids  and  the  urea 
are  lessened.  The  albumin  is  variable  in  amount ;  its  quantity  may, 
indeed,  fluctuate  much  in  the  same  patient,  and  even  change  from  day 
to  day.     It  is  persistent ;  yet  it  may  disappear  for  a  short  time. 

The  tube-casts,  too,  are  not  uniform, — not  nearly  so  much  so  as  in 
the  acute  variety  of  the  affection.  We  meet  with  hyaline  casts,  small 
or  large ;  with  casts  besprinkled  with  shrivelled  degenerating  epithe- 
lium ;  Avith  casts  covered  with  granules  or  with  oil-drops.  In  the 
progress  of  a  particular  case,  nearly  all  these  forms  may  be  encoun- 
tered, although,  as  we  shall  hereafter  see,  the  preponderance  of  any 
one  of  them  is  of  significance.  There  is  only  one  kind  we  do  not  find 
in  the  chronic  disorder  ;  the  one  covered  with  well-developed  epithelial 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     689 

cells  or  blood-corpuscles.  The  apparent  absence  of  casts  from  albu- 
minous urine  is  not  absolute  proof  of  the  non-existence  of  renal 
degeneration.  In  some  cases  their  absence  is  only  temporary,  while 
in  others  they  are  small  and  few  in  number  and  easily  escape  detec- 
tion. This  is  especially  the  case  in  the  contracted  kidney.  In  this 
disease  methylene-blue  is  much  more  slowly  excreted  by  the  kidneys 
than  in  other  forms  of  nephritis,  or  with  normal  urine.^ 

A  great  diversity  of  phenomena  is  thus  witnessed  in  chronic 
Bright's  disease,  and  the  different  grouping  of  the  symptoms  tells  us 
to  a  very  great  extent  the  form  of  the  chronic  malady  we  are  dealing 
with.  But  before  considering  its  varieties  let  us,  leaving  out  of  con- 
sideration those  affections  for  which  both  the  acute  and  the  chronic 
disease  may  be  mistaken,  and  which  have  been  already  discussed, 
consider  the  conditions  with  which  chronic  Bright's  disease  in  general 
may  be  confounded.     They  are  : 

Anjimia  ; 

Neuralgia  ; 

Chronic  Rheumatism  ; 

Chronic  Bronchitis  ; 

Asthma ; 

Disease  of  the  Heart  ;  Cardiac  Dropsy  ; 

Gastro-Intestinal  Disorders  ; 

Cancer  ;  Tuberculosis  ;  Cysts  of  KiDNEy  ; 

Chronic  Consecutive  Nephritis  ; 

PiENAL  Inadequacy. 

Ancemia. — There  are  few  diseases  which  alter  the  blood  so  com- 
pletely as  chronic  Bright's  disease,  and  the  gradual  impoverishment 
of  the  waste-laden  blood  makes  itself  manifest  by  the  increasing  de- 
bility, and  by  the  pallor  and  waxy  look  of  the  countenance.  We 
may  discriminate  this  well-marked  anaemic  condition  from  that  un- 
connected "with  renal  disease  by  the  existence  of  albumin  and  tube- 
casts  in  the  urine,  and  often  also  by  the  prominence  of  the  dropsical 
symptoms.  But  it  is  essential  to  know  that  some  of  the  phenomena 
— certainly  albuminous  urine  and  dropsy — may  attend  the  anaemia 
following  profuse  or  frequently  repeated  hemorrhages,  without  the 
structure  of  the  kidneys  having  been  impaired.  It  is  difficult  to  dis- 
tinguish these  cases  from  true  Bright's  disease,  except  by  taking  into 
account  the  diminution  of  the  albumin  as  the  hemorrhagic  tendency 
is  lost,  and  the  absence  of  tube-casts.  The  dropsy,  unless  it  be  con- 
siderable, can  hardly  be  looked  upon  as  a  valuable  differential  index, 

1  Bard  and  Bonnet,  Arch.  Gen.  de  Med.,  Feb.  and  March,  1898. 


690  MEDICAL  DIAGNOSIS. 

for  a  slight  or  moderate  amount  of  dropsy,  or  even  none,  may  be 
encountered  in  either  morbid  state.^ 

The  ophthalmoscopic  appearances  presented  by  the  retina  afford 
help  in  distinguishing  between  the  anaemia  of  Bright's  disease  and 
that  produced  by  any  other  cause.  Albuminuric  retinitis  is  not 
limited  to  any  form  of  Bright's  disease.  It  generally  happens  in 
both  eyes,  and,  though  in  the  chronic  variety  of  the  malady  it  may 
greatly  improve,  it  does  not  disappear.  The  sight  itself  deteriorates  ; 
and  we  have  attacks  of  blindness,  ureemic  amaurosis,  which  come 
on  suddenly  and  pass  off  suddenly. 

Neuralgia. — This  is  not  infrequent  in  the  chronic  form  of  Bright's 
disease.  Neuralgia  of  renal  origin  may  affect  the  fifth  nerve,  or 
other  nerves  ;  sometimes  it  takes  the  form  of  hemicrania,  and  it  is 
often  associated  with  disordered  vision,  or  with  impairment  of  other 
special  senses  ;  or  it  may  coexist  with  persistent  headache  or  with 
strange  and  anomalous  nervous  symptoms.  Headache  from  Bright's 
disease  may  also  be  present  without  neuralgia ;  it  may  be  of  the  nature 
of  megrim,  and  occur  in  paroxysms  attended  with  nausea  and  vomit- 
ing. 

Chronic  Rheumatism. — Frec[uently  patients  affected  with  chronic 
Bright's  disease  complain  of  muscular  pains.  The  pain  is  dull,  not 
increased  on  pressure ;  sometimes  shooting,  more  like  that  ordinarily 
termed  neuralgic.  The  pain  is  oftenest  met  with  in  those  instances  in 
which  the  dropsy  is  slight  or  wholly  wanting,  and  an  examination  of 
the  urine  is  then  the  only  means  of  determining  its  real  significance. 

Chronic  Bi'onchitis. — This  is  one  of  the  most  common  complica- 
tions of  Bright's  disease, — so  common,  indeed,  that  Bayer  observed  it 
in  seven-eighths  of  his  patients,  and  Wilks  ^  states  it,  from  an  extensive 
analysis  of  cases,  to  have  been  more  universal  than  any  other  single 
symptom,  albuminous  urine  alone  excepted.  It  is  hardly  necessary  to 
add  that  the  last-mentioned  sign  is  the  one  that  distinguishes  this  sec- 
ondary pulmonary  affection  from  all  other  forms  of  bronchial  disease. 

Renal  Asthma. — Whether  or  not  there  be  coexisting  bronchitis, 
attacks  of  shortness  of  breath,  like  paroxysms  of  asthma,  occur  as  the 
result  of  Bright's  disease.  This  renal  asthma  is  most  common  in  the 
chronic  contracted  kidney,  .It  has  no  features  by  which  it  can  be 
recognized  from  ordinary  asthma,  except  that  the  wheezing  and  the 

^  The  occurrence  of  marked  albuminuria  after  hemorrhage,  to  which  attention 
was  here  called,  has  been  since  studied  by  Fischl,  Arch.  f.  klin.  Med.,  Bd.  xxix., 
by  Quincke,  ibid.,  Bd.  xxx..  No.  4,  and  by  others. 

^  Guy's  Hospital  Reports,  2d  Series,  vol.  viii. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY   ORGANS.     691 

rales  are  not  so  marked,  and  that  it  does  not  subside  by  copious  ex- 
pectoration. It  more  resembles,  indeed,  cardiac  asthma,  and  is  most 
frequent  at  night. 

Disease  of  the  Heart;  Cardiac  Dropsy. — In  very  many  cases  of 
chronic  Bright's  disease  there  is  disease  of  the  heart,  particularly 
hypertrophy.  This  manifests  itself  by  the  ordinary  physical  signs  of 
hypertrophy.  The  vessels  become  more  tense  and  rigid,  especially  in 
contracted  kidney,  and  there  is  marked  accentuation  of  the  second 
sound  of  the  heart.  With  these  physical  signs,  dropsy  may  show 
itself,  and  in  chronic  parenchymatous  nephritis  frequently  does  so. 
With  kidney  and  heart  both  affected,  it  is  often  difficult  to  say  which 
is  the  primary  lesion  ;  either  will  occasion  albumin  in  the  urine. 

Let  us  suppose  that  in  cases  of  so-called  cardiac  dropsy  we  find 
albumin :  is  this  a  proof  of  coexisting  Bright's  disease  ?  Not  unless 
the  amount  of  the  abnormal  ingredient  be  considerable,  and  more 
than  occasional  tube-casts  accompany  the  albuminuria.  Mere  con- 
gestion of  the  kidneys,  resulting  as  it  does  from  an  obstruction  to  the 
flow  of  the  venous  blood  along  the  vena  cava,  may  occasion  albu- 
minuria ;  but  the  presence  of  albumin  is  temporary,  and  its  quantity 
small,  and  the  specific  gravity  of  the  urine  is  generally  high.  A  large 
amount  of  albumin,  persistent  and  conjoined  with  characteristic  tube- 
casts,  shows  that  changes  are  present  in  the  renal  textures.  When 
disease  of  the  heart  and  disease  of  the  kidney  are  combined,  it  is  the 
disease  of  the  kidney  which  generally  produces  the  disease  of  the 
heart.  The  cardiac  affection  does  not  give  rise  to  the  renal  affection 
nearly  as  frequently  as  supposed  ;  ^  yet  often  both  are  the  result  of  a 
common  cause,  as  a  general  cardiac-  and  arteriosclerosis, 

Gastro-Intestinal  Disorders. — These  are  among  the  most  usual 
consequences  of  the  renal  malady.  They  manifest  themselves  in 
various  ways  :  by  flatulency  and  indigestion  ;  by  diarrhoea  ;  by  nausea 
and  vomiting.  The  latter  symptoms  are  apt  to  occur  when  uraemic 
intoxication  is  developed.  They  may  be,  however,  also  met  with  at 
any  period  of  the  disease,  and  become  so  prominent  as  to  throw  into 
the  background  most  of  the  other  signs  of  the  renal  affection.  I  have 
seen  cases  of  Bright's  disease  which  first  manifested  themselves  by 
apparently  causeless  nausea  and  vomiting;  the  tongue  was  clean. 

The  intestinal  disorders  may  be  due  to  submucous  hemorrhage  in 
connection  with   the   changed  vessels   in  granular  kidney,  and  lead, 


^  See  proof  in  Middleton-doldsinillj  Lrclmv,  ISSS.  on  Hdntion  of  the  Diseases 
of  the  Kidney,  especially  tlu'  Hriiihrs  Diseases,  to  Diseases  of  tlie  Heart.  i)y  J.  M. 
Da  Costa. 


692  MEDICAL  DIAGNOSIS. 

as  Dickinson  has  pointed  out,  to  intestinal  ulceration  and  perfora- 
tion. 

Cancer  ;  Tubercle  ;  Cysts  of  Kidney. — These  morbid  products  affect 
the  kidneys  but  rarely, — at  all  events,  rarely  in  a  form  so  marked  as 
to  give  rise  to  conspicuous  clinical  phenomena.  In  all  of  them  there 
may  be  albumin  present  in  the  urine,  but  it  is  generally  in  small 
amounts,  and  mixed  with  some  ingredient  having  a  more  specific 
meaning.  Thus,  in  cancer  of  the  kidney  we  may  find  blood  with  the 
albumin ;  indeed,  hsematuria  is  a  very  important  symptom,  and  in 
some  instances  we  discern  with  the  microscope  cells  like  those  ob- 
served in  any  cancerous  growth ;  often  the  hemorrhages  are  profuse 
and  frequently  recurring,  are  preceded  by  severe  pain,  and  we  detect 
a  palpable  tumor  in  the  flank,  passing  upward  into  the  hypochon- 
driac region  and  downward  to  the  iliac  region,  or  even  forward,  not 
affected  by  the  act  of  breathing,  and  sometimes  causing  bulging  pos- 
teriorly. In  cases  of  melanotic  cancer,  whether  it  have  its  seat  in 
the  urinary  apparatus  or  elsewhere,  the  urine  becomes  dark  on  ex- 
posure to  the  air ;  there  is  melanuria.  In  children,  cancer  of  the 
kidney  is  not  a  rare  disease,  and  when  we  can  exclude  as  the  cause  of 
the  renal  tumor  cystic  degeneration  and  hydronephrosis — in  them  con- 
genital affections — we  can  diagnosticate  the  case  with  some  confidence. 
In  adults  the  diagnosis  is  always  doubtful,  at  least  when  the  disease  is 
primary.  A  rapid  and  irregular  growth  of  the  one-sided  renal  tumor, 
severe  pain,  bloody  urine,  emaciation,  and  cachexia  are  the  most 
certain  signs.  The  disease  is  twice  as  common  in  men  as  in  women. 
Sudden  and  rapidly  growing  varicocele  is  stated  to  be  a  symptom  of 
malignant  tumor.^  Syjjhilomata  of  the  kidney  may  be  suspected  from 
the  history,  but  cannot  be  recognized  with  certainty  ;  they  rarely  cause 
pain  or  produce  a  tumor  large  enough  to  be  detected,  but  mainly  give 
rise  to  the  ordinary  manifestations  of  chronic  Bright's  disease,^  most 
often  of  the  amyloid  form.  At  times  syphilis  of  the  kidney  shows 
itself  as  an  acute  syphilitic  nephritis.  In  sarcoma  of  the  kidney  the 
swelling  in  the  abdomen  attains,  in  children  especially,  very  great  size  ; 
hagmaturia  is  comparatively  rare,  and  the  peripheral  lymphatic  glands 
do  not  become  implicated.^ 

In  tubercle,  little  yellow  cheesy  masses  of  degenerated  tubercular 
matter  may  collect  as  a  sediment,  as  in  the  cases  referred  to  by  Fre- 


^  Guillet,  Tumeurs  malignes  des  Reins,  These  de  Paris,  1888. 
^Wagner,  Archiv  f.  klin.  Med.,  Bd.   xxviii.,   1881;  Mauriac,   Arch.   Gen.   de 
Med.,  Oct.  1886  ;  Jaccoud,  Gaz.  des  Hop.,  1888. 

3  Neumann,  Archiv  f.  klin.  Med.,  Bd.  xxx.,  1882. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     693 

richs  in  his  work  on  Brigiit's  disease.  The  tubercular  matter  is  gen- 
erally derived  from  the  pelvis  of  the  kidneys.  Witli  the  albumin,  pus 
and  other  signs  of  chronic  pyelitis  are  present.  The  disease  may  be 
primary,  or  the  infection  take  place  from  the  bladder,  the  prostate,  or 
the  ureters.  We  may  be  assisted  in  the  diagnosis  by  finding  tubercles 
in  other  organs,  as  in  the  lungs  ;  or  there  may  be  scrofulous  disease  of 
the  vertebrae.  In  tubercle  of  the  kidney,  extreme  pain,  occurring  in 
paroxysms  like  those  of  nephritic  colic,  is  a  very  important  sign.  This 
pain,  as  I  have  had  occasion  to  observe,  is  associated  with  frequent 
micturition,  and  is  temporarily  relieved  by  the  flow  of  water.  The 
urine  is,  however,  scanty,  and  generally  of  low  specific  gravity.  A 
moderate  amount  of  hsematuria  may  happen ;  tube-casts  are  rare ; 
the  patient  passes  at  times  little  fibrinous  shreds,  lias  irregular  fever, 
and  emaciates  steadily.  The  bacillus  of  tubercle  in  the  urine  serves 
as  a  means  of  diagnosis.  In  some  cases  the  kidney  most  diseased  en- 
larges sufficiently  to  form  a  tumor  discernible  through  the  abdominal 
walls. 

In  cysts  of  the  kidney — those  at  least  enclosing  ecliinococci — vesi- 
cles containing  the  characteristic  structures  of  the  parasites  may  be 
perhaps  detected.  Ordinary  cysts,  when  small,  are  not  to  be  recog- 
nized with  any  certainty  during  life :  nor  can  they  be  distinguished 
from  Bright's  disease ;  they  are,  indeed,  frequent  in  the  chronic  varie- 
ties of  this  disorder.  When  the  cysts  attain  decided  dimensions,  they 
give  rise  at  times  to  the  discharge  of  highly  bloody  urine,  and  to  albu- 
minuria, and  to  large  tumors,  which  may  be  detected  through  the  front 
walls  of  the  abdomen.  They  may  affect  one  or  both  kidneys,  pro- 
ducing slow  cachexia  and  enormous  abdominal  swelling.  Cysts  of  the 
kidney  and  liver  often  coexist.' 

Chronic  Consecutive  Nephritis. — In  consequence  of  affections  of  the 
bladder,  of  stone  in  the  bladder,  of  strictures  of  the  urethra,  of  disease 
of  the  ureters  and  of  the  prostate,  indeed  of  various  surgical  affections 
of  the  urinary  organs,  we  may  have  a  kidney  disease  established  which 
is  rather  a  form  of  slow  inflammatory  change  than  Bright's  disease.  It 
may  affect  only  one  or  both  kidneys,  and  tlie  diseased  organs  are  tough 
and  hard,  large  or  small,  and  show  great  increase  of  fibrous  tissue. 
The  source  of  irritation  which  has  led  to  the  secondary  inflammation 
is  at  times  in  the  kidney  itself,  in  the  shape  of  a  large  calculus  in  the 
pelvis. 

In  another  form  of  this  consecutive  nephritis  suppuration  takes 
place,  affecting  first  especially  the  pelvis  of  the  kidney,  a  suppurative 

1  Sal)Ourin,  Arch,  de  Phys.,  ix.,  1882. 


694 


MEDICAL   DIAGNOSIS. 


pyelonephritis, — the  condition  often  called  surgical  kidney.  It  is  diffi- 
cult to  distinguish  these  consecutive  forms  of  nephritis,  especially  where 
pus  is  found  in  the  urine,  either  from  the  condition  last  mentioned  or 
from  coexisting  bladder  disease,  except  by  thejhistory.  Very  often  there 
is  pain  along  the  course  of  the  ureter ;  and  the  urine,  when  passed  free 
from  pus,  contains  neither  albumin  nor  casts,  or  only  a  small  amount 
of  albumin  and  a  few  hyaline  casts.  The  urine  Js  apt  to  be  copious 
and  of  low  specific  gravity.     When  it  contains  pus  from  the  kidneys, 

Fig.  65. 


Fatty  casts  aud  epithelial  cells  filled  with  fat,  as  seen  in  the  discharge  coming  from  a  highly 

fatty  kidney. 

and  the  bladder  is  comparatively  unaffected,  the  purulent  urine  is  gen- 
erally acid.  The  heart  rarely  becomes  disturbed,  though  hypertrophy 
has  been  occasionally  noticed  in  the  non-suppurative  form.^ 

Renal  Inadequacy. — There  are  patients  who  pass  the  ordinary 
amount,  or  less  than  the  ordinary  amount,  of  urine  daily,  of  low  spe- 
cific gravity,  from  1002  to  1008,  not  containing  more  than  two  per 
cent,  of  urea,  though  the  uric  acid  may  be  normal,  and  who  in  conse- 
quence of  this  insufficient  action  of  the  kidneys  are  always  ailing  and 
weak,  take  cold  easily,  and  suffer  from  headache  and  nervousness. 
Even  if  they  drink  water  freely,  they  do  not  pass  more  urine  ;  this  does 
not  contain  albumin  or  casts,  differing  m  this  respect  from  Bright's 
disease.  But  dropsy,  as  Sir  Andrew  Clark,  who  first  descrUDed  the 
complaint,^  states,  with  puffy  face  and  dry,  glossy  skin,  may  happen, 
and  a  state  similar  to  myxcedema  be  gradually  developed. 

Having  now  treated  of  chronic  Bright's  disease  as  one  affection,  I 


'  Fagge's  cases,  in  Practice  of  Medicine,  1886,  vol.  ii.  p.  483. 
^  British  Medical  Journal,  vol.  i.,  1883. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     695 

shall  briefly  refer  to  the  distinctions  between  its  forms,  lifso  doing, 
I  shall  follow  the  classification  based  on  the  diversified  anatomical 
aspect  of  the  kidneys. 

First  there  is  the  chronic  enlargement  of  the  organ,  of  which  several 
kinds  exist : 

1.  The  enlarged  chronically  inflamed  kidney,  known  also  as  the 
large  white  kidney,  or  as  chronic  parenchymatous  nephritis.  This 
variety  of  the  malady  may  or  may  not  be  preceded  by  acute  nephritis. 
It  may  last  for  a  few  years,  but  generally  terminates    fatally  before 


Hyaline  or  waxy  casts,  magnified  a]x)ut  460  diameters.  On  some  of  them  are  scattered  a  few 
shrivelled  epithelial  cells  and  oil-drops;  the  large  cells  to  the  left  are  epithelial  cells  from  the 
bladder. 

The  kind  of  casts  here  depicted  may  be  found  in  any  foi-m  of  Bright's  disease,  acute  as  well  as 
clironic.  In  the  waxy  kidney,  however,  they  vastly  preponderate,  and  are  of  large  size,— many 
much  larger  than  those  in  this  figure. 

that  time.  The  urine  is  diminished  in  urea  and  pigment  and  in  chlo- 
rides ;  it  contains  large  amounts  of  albumin  and  granular  and  epithe- 
lial casts,  with  some  hyaline  casts  and  a  few  slightly  oily  casts.  The 
dropsy  occasioned  is  extensive  and  persistent,  and  there  is  usuahy 
little  difficulty  in  tracing  it  to  an  acute  attack.  Sometimes  the  dropsy 
lessens  materially,  then  actively  recurs.  The  large  kidney  rarely 
contracts  ;  but  it  may  do  so.  The  large  white  kidney  may  also  pass 
into  the  fatty  kidney.  Dilatation  of  the  heart  is  common  in  chronic 
parenchymatous  nephritis,  more  common  even  than  pure  hypertrophy, 
which  is  more  usual  in  contracted  kidney. 

2.  The  fatty  kidney.  The  kidney  is  very  large  and  fatty.  The 
convoluted  tubes  are  filled  with  oil,  accumulated  in  their  epithelial 
cells.  The  fatty  disease  is  recognized  by  the  numerous  oily  casts,  fatty 
cells,  and  free  oil-cells  which  appear  in  the  highly  albuminous  urine. 


696  MEDICAL  DIAGNOSIS. 

It  is  a  fatal  complaint,  generally  very  chronic  in  its  course,  and  attended 
with  persistent  dropsy.  Tliis  morbid  condition  must  not  be  confounded 
with  a  simply  fatty  kidney,  such  as  is  sometimes  found  in  phthisis  or 
oftener  in  drunkards,  and  which  is  not  associated  with  albummous 
urine.  A  certain  amount  of  fatty  casts  and  fatty  cells  may  appear  in 
the  urine  and  not  be  persistent  or  indicate  the  real,  dangerous  fatty 
kidney.  Acute  nephritis  from  cold  and  exposure  is  much  more  apt  to 
be  followed  by  fatty  kidney  than  the  acute  nephritis  attending  scarlet 
fever,  wiiich  is  more  likely  to  pass  into  the  large  white  kidney.  A 
fatty  kidney  is  sometimes  combined  both  with  the  granular  and  with 
the  lardaceous  kidney. 

3.  The  u-axy  or  amyloid  kidney  is  the  result  of  a  general  lardaceous 
or  waxy  disease  involving  the  kidneys  in  common  with  other  organs, 
and  generally  following  upon  protracted  suppuration  from  any  cause, 
either  wound  or  disease.  The  urine  is  increased  in  quantity  in  the 
earlier  stages,  and  of  low  specific  gravity ;  it  contains  much  albu- 
min, but  not  many  casts.  Those  which  are  seen  are  pale,  and  for  the 
most  part  hyaline,  or  highly  refracting,  structureless  moulds  of  the 
tubules  of  large  diameter ;  they  may  or  may  not  give  the  characteristic 
amyloid  reaction,  the  red  color  when  treated  with  a  watery  solution 
of  iodine  and  of  potassium  iodide.  Methyl-green  colors  amyloid  sub- 
stances an  intense  green.  It  is  used  for  staining  in  the  form  of  a  one 
per  cent,  aqueous  solution.  Methyl-green  colors  hyaline  casts  in  situ 
ultramarine  blue,  so  that  these  also  can  be  readily  distinguished  in 
sections  of  the  kidney  from  the  green-colored  tissues  around,  in  which 
they  may  lie.  Blood  is  rarely  present  in  the  urine  of  the  amyloid 
kidney,  and  the  urea  is  but  slightly  diminished  in  quantity.  Diarrhosa 
frequently  coexists,  and  the  liver  and  spleen  are  apt  to  be  enlarged ; 
but  the  heart  is  not  affected.  The  dropsy  is  absent  or  trifling  m 
amount,  yet  its  persistence  while  the  urine  is  increased  in  quantity  is 
peculiar  to  this  form  of  renal  disease,  and  it  may  exist  markedly  as  a 
late  symptom ;  the  patient  is  sallow-looking  and  emaciated ;  his  dis- 
ease may  last  for  years. 

In  laying  stress  on  the  hyaline  and  waxy  casts  we  must  be  careful 
not  to  confound  them  with  those  still  larger  mucous  moulds  of  the 
uriniferous  tubules,  or  mucous  casts.  They  are  also  smooth,  but  of 
enormous  length,  sulDdividing  into  smaller  ones,  and  of  cylindrical 
shape.  They  are  met  with  in  acute  parenchymatous  nephritis,  but 
occur  particularly  in  consequence  of  transmitted  irritation  from  the 
bladder,  and  are  then  associated  with  small  amounts  of  albumin  and 
of  pus.  Yet  unless  the  latter  be  present  there  is  no  albumin,  or  the 
merest  trace.     Further,   flask-shaped   hyaline   bodies   and   cylinders 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     697 

may  be  moulds  of  the  vesicles  and  smaller  ducts  of  diseased  pros- 
tates.^ 

4.  Then  we  have  the  small  contraeted  kidney,  the  granular  kidney, 
or  interstitial  nephritis  or  renal  cirrhosis.  This  form  of  disease  is 
frequently  found  in  gouty  persons,  in  alcoholics,  or  after  prolonged 
mental  anxiety  and  distress,  or  in  connection  with  general  arterio- 
sclerosis, or  as  the  result  of  lead  poisoning.  The  urine  shows  but  an 
inconsiderable  amount  of  albumin  ;  the  tube-casts  are  granular,  or  sim- 
ple fibrinous  moulds,  generally  small,  sometimes  large ;  here  and  there 

F:g.  67. 


Granular  casts,  or  casts  covered  with  disintegrating  epithelium  and  granules.  Casts  of  this  char- 
acter are  chiefly  found  in  the  chronic  inflammatorj-  forms  of  Bright's  disease,  both  parenchymatous 
and  interstitial.    The  granular  matter  may  be  coarse  and  dark. 

a  little  oil  is  observed.  But  though  the  urine  may  contain  only  small 
amounts  of  serum-albumin  and  of  globulin,  there  may  be  a  consider- 
able quantity  of  other  proteid  matter  in  the  shape  of  albuminose." 
Dropsy  is  absent  in  a  certain  proportion  of  cases,  and  when  present 
is  generally  slight.  It  often  disappears  for  a  while  and  returns.  The 
urine  is  increased  in  quantity,  although  towards  the  termination  it 
may  become  scanty  or  even  suppressed.  Dyspepsia,  puffy  eyehds, 
chronic  bronchitis,  increased  arterial  tension,  hypertrophied  ventricles, 
albuminuric  retinitis,  headache,  and  disorder  of  the  nervous  system 
are  common  symptoms.  The  malady  runs  a  very  chronic  course.  It 
is  chiefly  characterized  anatomically  by  an  affection  of  the  fibrous  tis- 
sues surrounding  the  Malpighian  corpuscles  and  lying  between  the 
tubes,  a  slow^  increase,  followed  by  a  slow  contraction,  of  the  inter- 

^  Sir  Andrew  Clark,  Transactions  of  the  Clinical  Society  of  London,  vol.  xix., 
1886. 

'^  Rose  Bradford  in  Allhntt's  System  of  Medicine,  vol.  iv.  p.  304. 


698  MEDICAL  DIAGNOSIS. 

tubular  fibrous  tissue  and  atrophy  of  the  tubules,  connective-tissue 
changes  in  the  renal  plexus/  and  fibroid  changes  in  the  small  vessels 
of  the  body.  The  sphygmograph  shows  marked  pulse-tension,  and 
this,  with  altered  specific  gravity,  has  been  noticed  before  albumin  is 
present  in  the  urine.  In  the  uric  acid  or  gouty  nephritis,  uric  acid 
deposits  may  be  found  in  the  straight  tubes  of  the  medullary  sub- 
stances. A  chronic  interstitial  nephritis  may  be  also  associated  with 
deposits  of  hme,  which  take  place  very  generally  in  the  uriniferous 
tubules  in  the  cortex.  These  lime  deposits  may  be,  as  Virchow  points 
out,  calcareous  matter  washed  into  the  kidney  from  diseased  bone. 

In  contracted  kidney,  especially  in  the  earlier  stages,  albumin,  even 
casts,  may  be  absent  from  the  urine,  and  we  may  have  to  recognize 
the  malady  rather  by  the  hypertrophied  heart  and  thickening  of  the 
vessels,  the  high  arterial  pressure,  the  accentuation  of  the  second  sound 
of  the  heart,  the  headache,  vertigo,  nausea,  breathlessness,  retinal 
changes,  and  the  anaemia.  The  urine  may  be  of  low  specific  gravity 
and  copious,  but  there  are  many  exceptions  to  this  ;  it  is  generally  de- 
ficient in  urea.  A  few  hyaline  or  granular  casts  are  at  times  found ; 
and  the  albumin  may  not  be  entirely  absent,  but  appears  every  now  and 
then  in  traces.  There  may  be  even  chronic  general  oedema  present 
without  albuminous  urine,^  and  various  nervous  and  mental  symptoms. 

Stewart^  has  called  attention  to  cases  of  chronic  granular  kidney  with- 
out albumin,  though  generally  with  hyaline  or  finely  granular  casts,  and 
with  cylindroids,  but  with  habitual  diminution  in  the  amount  of  urine 
and  of  the  urinary  solids,  especially  the  urea,  and  with  symptoms  of 
retention  of  nitrogenous  waste.  Among  these,  debility,  headaches,  and 
vertigo  are  very  prominent ;  there  are  no  cardio-vascular  changes. 

Cases  of  fibroid  kidney  following  generalized  arteriosclerosis  can- 
not be  distinguished  from  primary  granular  kidney,  except  by  the  his- 
tory of  previous  organic  change  in  the  heart  and  blood-vessels.  Nor 
is  the  distinction  of  any  importance.  Chronic  interstitial  nephritis 
may  be  wholly  latent,  and  nothing  but  an  attack  of  endocarditis  or 
pericarditis,  or  apoplexy,  or  convulsions  call  attention  to  its  existence. 

The  different  kinds  of  albumin  have  been  above  mentioned.  Of 
these  serum-albumin  and  serum-globulin  are  by  far  the  most  important, 
and  have  much  the  same  chnical  significance.  With  reference  to  the 
tube-casts,  no  special  kind  is  of  diagnostic  value  ;  it  is  the  preponderance 
of  the  type  alone  that  is.     Hyaline  casts  have  the  least  significance. 

1  Da  Costa  and  Longstreth,  Amer.  Journ.  Med.  Sci.,  July,  1880. 
-  As  in  Case  31  of  Mahomed's  paper  on   Chronic  Bright'?   Disease  without 
Albuminuria,  Guy's  Hospital  Reports,  3d  Series,  vol.  xxv. 

3  Transactions  of  the  Association  of  American  Physicians,  vol.  xii.,  1897. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     699 

In  the  following  table  the  clinical  differences  between  the  various 
forms  of  Bright's  disease  are  set  forth : 

Table  exhibiting  the  Clinical  Differences  between  the  Principal  Forms  of  Bright's 

Disease. 


Acute  Cases  in  which  Dropsy  occurs  quickly  and  is  extensive. 
Caused  mostly  by  exipo- 
sure,  or  scarlet  fever. 
Dropsy  extensive,  gen- 


Acute  Bright's  dis- 
ease; acute  des- 
quamative or  tubal 
nephritis ;  acute  pa- 
renchymatous ne- 
phritis; aoute  renal 
dropsy  


erally  begins  in  the 
eyelids  or  in  the  feet ; 
usually  fever ;  uree- 
mia  may  be  met 
with.  Disease  most 
common  in  child- 
hood and  among 
young  adults. 
Recovery  frequent ; 
but  disease  may  ter- 
minate in  chronic 
parenchymatous  ne- 
phritis. 


Urine  usually  scanty, 
deephcolored,  of  high 
specific  gra^^ty,  con- 
taining much  albu- 
min, often  blood ; 
also  b  1  o  o  d-c  a  s  t  s  ; 
casts,  many  of  large 
size,  covered  with 
epithelium,  and  a 
few  hyaline  and 
granular  casts ;  and 
free  epithelial  cells, 
cloudy  and  granu- 
lar; urea  dimin- 
ished . 


Kidneys  enlarged,  con- 
gested or  mottled, 
shedding  epithe- 
lium ;  cortical  sub- 
stance  increased; 
cones  usually  redder 
than  cortical  s  u  b- 
stance.  Dilated  con- 
voluted tubes,  dis- 
tended with  swollen, 
cloudy  epithelium ; 
at  ends  of  tubules 
also  blood  or  plugs 
of  fibrin. 


Chronic  Cases  in  which  Dropsy  is  variable  in  amount  and  may  be  absent. 
■  History  often  of  ante- 
cedent acute  inflam- 


Chronic  parenchym- 
atous nephritis: 
chronic  tubal  ne- 
phritis ;  chronic  dif- 
fuse nephritis ;  large 
white  kidney 


Fattv  Bright's  kidncv, 


Waxy  kidney ;  larda- 
ceous  or  amyloid 
degeneration  of  kid- 
ney   


matory  attack; 
dropsy  a  prominent 
sj-mptom.  Marked 
antemia ;  puffy  face. 
Inflammations  of  se- 
rous membranes  and 
ursemia  not  uncom- 
mon ;  hypertrophy 
of  heart,  especially 
of  the  left  ventricle, 
or  dilatation. 
Recovery  possible,  but 
doubtful. 

Persistent  and  obsti- 
nate dropsy,  coming 
on  gradually ;  face 
pale  and  puffed  ;  hy- 
pertrophy of  heart 
affecting  often  both 
sides. 

Always  fatal. 

Follo^^'s  usually  wast- 
ing diseases,  syphilis, 
caries,  and  long-con- 
tinued suppuration. 
Rare  in  very  early 
and  in  advanced  age. 

Dropsy  trifling,  except 
late  in  disease ;  great 
emaciation ;  striking 
sallowness  of  face ; 
liver  and  spleen  en- 
1  a  r  g  e  d  ;  diarrlKra  : 
much  thirst ;  lieart 
not  affected  ;  n  c  r- 
vous  sjTiiptoms  in- 
frequent. 

I  'n  fiivora1)lc  ]  irognosis. 


Urine  in  normal  or  in 
increased  quantity  ; 
specifle  gravity 
somewhat  below 
normal ;  urea  dimin- 
ished ;  albumin  gen- 
erally in  consider- 
able amount ;  granu- 
lar casts ;  at  times 
compound  granule- 
cells  and  partially 
fatty  epithelium ;  no 
blood-casts ;  leuco- 
cytes. 

Urine  contains  much 
albumin,  fatty  casts, 
fatty  epithelial  cells, 
free  oil.  Spec.  grav. 
variable,  usually 
from  1015  to  1030. 
Quantity  variable, 
generally  moderate 
or  diminished  ;  urea 
diminished. 

Urine  increased,  con- 
tains much  albumin, 
but  few  casts,  which 
are  pale  and  trans- 
parent or  highly  re- 
fracting. The  casts 
may  or  may  not  give 
the  mahogany-red 
reaction  w  i  t  li  a 
water)-  solution  of 
iodine.  Spec.  grav. 
low,  yet  usually 
a  1)  o  V  e  1010  ;  urea 
normal  or  sliglitly 
diminislied. 


Kidneys  large,  pale, 
capsules  easily 
stripped  off,  cortical 
substance  greatly  in- 
creased ;  cones  may 
be  of  natural  color  : 
tubes  irregularly  dis- 
t ended,  and  filled 
with  granular  epi- 
thelium and  with 
detritus.  Thicken- 
ing of  intertubular 
matrix. 


Kidneys  enlarged,  and 
very-  fatty;  s  o  m  e- 
times  have  a  mottled 
look.  The  tubes,  es- 
pecially the  convo- 
luted ones,  full  of 
highly  fatty  epithe- 
lium, and  free  oil. 


K  i  d  n  e  y  s  enlarged , 
smooth,  and  waxy- 
looking  ;  capsule 
easily  detached ;  cor- 
tex pale,  anaemic ; 
reddish-brown  d  i  s- 
colorationon  testing 
with  watery  solution 
of  iodine;  cones 
often  dark  and  con- 
gested. Morbid 
process  at  first 
chiefly  along  renal 
vessels. 


700 


MEDICAL  DIAGNOSIS. 


Table  exhibiting  the  Clinical  Differences  between  the  Principal  Forms  of  Bright's 

Disease. — Continued. 
Chronic  Cases  in  which  Dropsy  is  variable  in  amount  and  may  be  absent. — Continued. 

Kidneys  waste  slowly, 


Chronic  contraction  of 
the  kidney;  c  o  n- 
tracted  kidney ;  cir- 
rhosis of  the  kid- 
ney ;  interstitial  ne- 
phritis ;  granular 
kidney ;  fibroid  kid- 
.  ney  ;  gouty  kidney . . 


Dropsy  slight,  fre- 
quently absent ; face 
sallow ;  often  head- 
ache and  retention 
of  urea,  tendency  to 
coma,  and  to  convul- 
sions ;  vertigo ;  anse- 
mia ;  epistaxis  ;  reti- 
n  i  t  i  s  ;  hypertrophy 
of  heart;  liver  may 
be  cirrhosed.  Most 
common  between 
forty  and  sixty  years 
of  age. 

May  exist  for  years 
unsuspected ;  is  a 
very  chronic  disease. 


Urine  more  copious 
than  in  health,  yet 
extremely  small 
amount  of  albumin, 
this  at  times  tempo- 
rarily absent;  hya- 
line and  large  finely 
granular  casts ;  al- 
tered epitheliuni ;  a 
little  oil. 

Spec.  grav.  low ;  rarely 
above  1010,  much 
oftener  below ;  urea 
decreases  gradually ; 
marked  decrease 
later  in  disease. 


become  dense  and 
contracted ;  capsule 
very  adherent ;  sur- 
face often  granular ; 
thickness  of  the  cor- 
tical substance  di- 
minished; cysts 
common.  There  is 
hypertrophy  of  con- 
nective tissue ;  com- 
pression and  atrophy 
of  g  1  a  n  d-elements 
and  of  tubules. 
C  a  r  d  i  o-v  a  s  c  u  1  a  r 
changes.  Tissue 
changes  in  renal 
ganglia. 


Diseases  associated  with  Purulent  Urine. 

In  every  case  in  Avhich  pus  in  any  quantity  is  detected  in  the 
urine,  it  becomes  of  great  importance  to  ascertain  primarily  that  it  is 
not  derived  from  the  urethra,  from  the  vagina,  or  from  an  abscess  that 
has  opened  into  the  urinary  passages.  The  first  point  we  may  decide 
by  examining  into  the  history  of  the  case,  and,  if  necessary,  by  an 
exploration  of  the  parts,  as  well  as  by  an  examination  of  the  urine 
procured  in  the  manner  recommended  in  the  first  part  of  this  chap- 
ter ;  the  second,  by  the  same  means,  and  by  determining  that  a  dis- 
charge takes  place  equally  when  no  urine  is  voided ;  the  third  is  more 
difficult  to  make  out,  but  there  is  generally  something  in  the  symp- 
toms and  in  the  history  of  the  case  furnishing  a  clue  to  its  inter- 
pretation,— such,  for  instance,  as  the  sudden  appearance  of  a  large 
quantity  of  pus  in  the  urine.  Having  excluded  each  of  these  morbid 
states  as  the  source  of  the  purulent  urine,  we  next  turn  to  see  which 
of  the  maladies  that  are  its  most  common  cause  is  before  us.  They 
are : 

Acute  Cystitis. — Acute  inflammation  most  frequently  affects  the 
mucous  membrane  at  or  near  the  neck  of  the  bladder.  It  is  much 
more  commonly  encountered  in  men  than  in  women,  and  in  adults 
than  in  children.  Its  main  symptoms  are  a  feeling  of  weight  and  pain 
in  the  hypogastric  region,  augmented  by  movement  and  by  pressure. 
The  pain  does  not,  however,  remain  confined  to  the  region  about  the 
bladder,  but  is  felt  also  in  the  iliac  and  sacro-lumbar  regions.  It  is 
attended  with  considerable  febrile  disturbance  and  extreme  irritability 
of  the  affected  viscus.  The  urine  is  voided  drop  by  drop,  and  its 
passage  is  accompanied  by  straining  and  a  scalding  sensation  at  the 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     701 

neck  of  the  bladder ;  it  is  high-colored,  cloudy  from  vesical  mucus, 
and  contains  blood  and  pus  and  sometimes  shreds  of  lymph.  At 
first  the  urine  is  acid.  The  acute  disease  generally  terminates  within 
a  week,  leaving  often  an  irritable  bladder  or  a  chronic  inflammation. 

The  symptoms  of  acute  cystitis  are  similar  to  those  of  acute  painful 
nephritis,  and  the  exciting  causes  may  be  much  the  same.  But  acute 
inflammation  of  the  bladder  differs  from  acute  inflammation  of  the 
kidney  by  the  far  greater  severity  of  the  pain,  its  much  lower  posi- 
tion, and  by  the  distress  in  voiding  the  urine.  Neuralgia,  or  spasm, 
of  the  bladder  may  be  distinguished  from  acute  inflammation  by  the 
absence  of  fever,  and  by  the  sharp,  lancinating,  but  paroxysmal  pain, 
each  onset  of  which  lasts  hardly  longer  than  from  two  to  six  hours, 
and  is  attended  with  difficulty  in  passing  water,  which  disappears  as 
the  pain  subsides. 

Metritis  exhibits  several  of  the  traits  of  cystitis :  we  find  the  same 
hypogastric  pain  shooting  to  the  thighs  or  to  the  anus  and  loins,  the 
same  feeling  of  weight  in  the  perineum,  and  the  same  signs  of  irri- 
tation of  the  bladder  and  of  fever.  As  it,  however,  generally  occurs 
in  the  puerperal  state,  we  have  the  history,  and  the  character  of  the 
discharges  from  the  vagina,  to  guide  us,  as  well  as  the  knowledge  to 
be  gained  by  a  local  examination. 

Chronic  Cystitis. — This  affection,  often  called  chronic  vesical 
catarrh,  is  common  in  advanced  age.  It  generally  comes  on  in  an 
insidious  manner,  and  is  excited  by  some  obstacle  to  the  evacuation 
of  urine,  such  as  a  stricture,  or  by  the  presence  of  a  stone  in  the  blad- 
der, or  by  an  enlargement  of  the  prostate  gland.  A  paralysis  of  the 
viscus  leading  to  retention  of  its  contents,  or  a  serious  structural  dis- 
ease of  its  coats,  whether  malignant  or  non-malignant,  may,  however, 
also  establish  the  morbid  process. 

The  most  usual  symptoms,  indeed  in  every  way  the  most  charac- 
teristic, are  dull  pain,  a  frequent  desire  to  pass  water,  and  the  discharge 
of  a  large  quantity  of  muco-pus  or  pus  with  each  act  of  micturition. 
The  urine,  which  is  alkaline,  on  standing  deposits  a  glairy,  viscid  sed- 
iment, in  which,  under  the  microscope,  vesical  epithelial  triple  phos- 
phates, large  pus-corpuscles,  extremely  regular  both  in  contents  and 
in  shape,  and  pathogenic  germs,  especially  the  bacillus  coli  communis 
and  the  staphylococcus  pyogenes,  may  be  detected.  The  urine  usu- 
ally contains  more  albumin  than  is  found  in  acute  cystitis. 

The  diagnosis  of  the  disease  in  males  is  easy.  The  only  affection 
with  which  it  is  liable  to  be  confounded  is  abscess  of  the  kidney.  In 
females,  uterine  disorders  may  so  closely  simulate  it  that  it  may 
require  a  local  examination  to  tell  the  difference. 

44 


702  MEDICAL   DIAGNOSIS. 

But,  having  decided  the  case  to  be  one  of  chronic  cystitis,  it  is 
always  more  difficult  to  discover  its  exciting  cause.  We  have  to 
depend,  to  a  great  extent,  upon  the  history  of  the  malady ;  its  as- 
sociation with  a  stone  can  be  determined  only  by  the  use  of  the 
sound. 

Abscess  of  the  Kidney. — This  dangerous  condition  is  the  result 
of  suppurative  inflammation  of  the  kidney,  or  of  abscesses  forming 
in  connection  with  pyemia,  or  with  embolism.  The  suppurative 
inflammation  is  sometimes  traceable  to  an  acute  attack  of  nephritis 
brought  on  by  exposure  or  by  external  violence,  to  retention  of  urine, 
or  to  the  impaction  of  a  renal  calculus  ;  but  at  other  times  it  origi- 
nates without  any  assignable  cause,  and  in  an  insidious  way.  The 
association  of  suppurative  nephritis  with  erysipelas  has  engaged  much 
attention,  and  the  renal  affection  is  even  thought  to  be  erysipelatous 
in  its  origin.^  Abscess  of  the  kidney  may  also  arise  from  acute  inter- 
stitial nephritis  and  in  suppuration  that  occasions  surgical  kidney. 

Abscess  of  the  kidney  is  a  rare  disease.  It  has  much  the  same 
symptoms  as  pyelitis.  There  is  a  fulness  on  one  side  of  the  spine 
associated  with  tenderness  on  deep  pressure  in  the  lumbar  region, 
and  with  more  or  less  constant  pain,  the  pain  and  tenderness  being 
increased  by  lying  on  the  affected  side  ;  there  are  also  fever  and  oc- 
casional rigors,  digestive  disturbances,  and  blood  and  pus  in  the  scanty, 
acid  urine,  though  pus  in  the  urine  may  be  absent.  In  some  cases  a 
marked  tumor  is  found  in  the  loin,  extending  towards  the  iliac  fossa. 
If  the  abscess  burst  into  the  calyces,  there  occurs,  simultaneously 
with  a  subsidence  of  the  tumor,  a  sudden  and  copious  discharge  of 
pus  with  the  urine,  or,  if  it  break  into  the  intestine,  with  the  fecal 
evacuation. 

The  disease  almost  never  affects  more  than  one  kidney  ;  hence  so- 
called  ursemic  symptoms  are  rarely  met  with,  since  the  healthy  kid- 
ney enlarges  and  becomes  capable  of  performing  a  double  amount  of 
work.  Ebstein^  has,  however,  observed  that  chronic  abscess  in  one 
kidney  may  produce  amyloid  disease  of  the  other.  The  disorder 
gradually  leads  in  most  cases  to  a  fatal  issue,  from  the  irritation,  the 
vomiting,  the  diarrhoea,  the  wasting  discharge,  and  the  protracted 
hectic ;  sometimes  paralysis  of  one  or  both  legs  happens,  adding 
greatly  to  the  distress.  There  is  a  possibility  of  recovery,  if  the 
patient  have  strength  enough  to  withstand  the  purulent  drain  until 
the  abscess  empties  itself.     It  may  do  this  through  the  urinary  pas- 

^  Goodhart,  Guy's  Hospital  Reports,  3d  Series,  vol.  xix. 
^  Ziemssen's  Cyclopa;dia. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     703 

sages,  through  the  colon,  through  the  lumbar  muscles,  through  the 
diaphragm,  and  be  evacuated  by  coughing,  and  the  cavity  of  the  ab- 
scess then  cicatrizes  ;  or  the  abscess  may  burst  into  the  peritoneal 
cavity  and  cause  rapid  death. 

The  diseases  for  which  the  malady  is  most  apt  to  be  mistaken — 
leaving  out  those  extremely  rare  cases  in  which  abscesses  from  dis- 
eased vertebrae  break  suddenly  into  the  urinary  tract — are  chronic 
cystitis,  permephritis,  and  pyelitis.  From  cystitis  it  may  be  distin- 
guished by  the  dissimilar  local  signs  and  the  different  appearances  of 
the  urine.  Thus,  in  the  affection  of  the  bladder  the  quantity  of  pus 
constantly  discharged  is  far  greater, — for  in  abscess  of  the  kidney 
there  are  times  when  little  or  no  pus  is  voided  ;  on  the  other  hand, 
the  urine  of  the  vesical  disorder  is  less  albuminous.  In  the  renal 
malady  we  can  detect  casts  and  other  renal  products  in  the  sediment. 

Perinejyhritis  unconnected  with  inflammation  of  the  kidney  is  a 
very  rare  disease.  When  primary,  it  may  result  from  exposure  ;  but 
it  is  more  generally  due  to  contusion  or  strain.  I  saw  an  instance  of 
it  in  a  young  man  who,  returning  home  from  a  long  walk,  strained  his 
back  in  jumping  a  fence.  An  abscess  gradually  formed,  giving  rise  to 
a  slight  fulness  in  the  left  lumbar  region  and  severe  pain,  which  dis- 
appeared as  matter  was  discharged  through  the  integuments.  The 
function  of  the  kidney  was  not  affected. 

But  an  external  opening  may  be  established  when  the  process  of 
inflammation  and  suppuration  has  begun  in  the  kidney  and  thence 
spread  to  the  loose  tissues  surrounding  it.  Under  these  circum- 
stances, the  appearance  in  the  urine  of  pus  prior  to  its  discharge 
through  the  muscles  of  the  back  would  be  the  only  certain  means  by 
which  we  could  judge  where  the  suppuration  had  primarily  taken 
place.  The  inflammation  may  travel  upward  from  the  pelvic  viscera 
or  from  the  head  of  the  colon  or  the  appendix ;  it  has  been  also 
noticed  after  irritation  of  the  testicles  and  of  the  spermatic  cord.  The 
pus  is  generally  situated  behind  the  kidney.  Secondary  perinephritis 
has  been  observed  in  pyaemia,  and  after  typhoid  and  typhus  levers, 
smallpox,  and  the  other  exanthemata.  The  disease  is  not  uncommon 
in  childhood.^ 

The  prominent  symptom  in  perinephritis  is  pain,  which  at  times 
is  so  severe  as  to  confine  the  patient  to  bed  with  his  knees  flexed, 
with  a  sense  of  fulness  and  dragging  weight,  with  tenderness  in  the 
region  of  the  kidney,  and  with  lameness  owing  to  the  interference 
with  the  play  of  the  psoas  muscles.    The  urine  is  generally  unaltered, 

^  Gibney  reports  twenty-eight  cases,  Amer.  Journ.  of  Obst.,  Ajjril,  1876. 


704  MEDICAL  DIAGNOSIS. 

or  only  full  of  urates ;  the  bowels  may  be  constipated,  owing  to  the 
pressure  of  the  tumor  on  the  intestine.  A  rounded,  doughy,  and 
generally  indolent  swelling,  uninfluenced  by  the  respiratory  move- 
ments, is  usually  found  in  the  lumbar  region  or  a  little  lower.  The 
abscess  may  cause  pulmonary  or  pleuritic  complications,  but  rarely 
gives  rise  to  jaundice.  As  the  disease  advances,  severe  chills,  with 
high  fever  and  copious  night-sweats,  occur,  as  well  as  emaciation  and 
marked  debility,  and  the  thoracic  symptoms  may  mask  the  renal ; 
fluctuation  may  be  at  times  detected,  and,  before  the  abscess  breaks 
externally,  a  phlegmonous  appearance  of  the  skin  where  the  abscess 
points  is  not  unusual.     Great  relief  follows  the  discharge  of  the  pus. 

From  inflammation  of  the  psoas  muscle  we  distinguish  perinephritis 
by  the  absence  of  marked  sensitiveness  over  the  renal  region  in  the 
former  complaint,  and  by  flexion  of  the  thigh  in  it  producing  pain. 

Pyelitis. — Inflammation  of  the  mucous  membrane  of  the  pehis 
of  the  kidney  is  almost  never  idiopathic,  being  commonly  caused  by  a 
calculus  arrested  in  the  ureter ;  or  by  a  retention  of  urine  from  an 
obstacle  in  the  ureter,  bladder,  or  urethra ;  or  by  an  extension  upward 
from  the  bladder  of  an  inflammation.  Bright's  disease  and  diaJDetes 
are  not  unusually,  and  typhus  and  the  eruptive  fevers,  pyaemia,  scurvy, 
diphtheria,  carbuncle,  puerperal  septicsemia  are  occasionally,  compli- 
cated with  some  degree  of  pyelitis.  Pyelitis  may  be  also  catarrhal  or 
rheumatic.  Under  these  circumstances,  and  in  all  the  infectious  dis- 
eases, pyelitis  is  apt  to  show  itself  in  an  acute  form. 

The  symptoms  of  the  chronic  malady  are  in  part  those  produced 
by  the  morbid  states  exciting  it,  especially  those  denoting  a  calculus 
lodged  in  the  kidney  or  arrested  in  its  transit  towards  the  bladder ; 
partly  those  directly  traceable  to  the  inflammation  of  the  pelvis  and 
infundibula.  The  manifestations  of  the  latter  disorder  are  a  constant 
dull  pain  m  the  loin,  felt  also  in  the  course  of  the  ureter,  and  the  pas- 
sage of  pus  and  occasionally  of  small  €|uantities  of  blood  with  the 
urine  ;  in  cases  from  retention  and  decomposition  of  urine  there  are 
recurring  chills,  sweats,  vomiting,  headache,  delirium,  and  fever.  In 
most  cases  of  pyelitis  the  urine  is  acid,  albuminous,  very  abundant, 
and  offensive.  It  may  be  acid  even  if  it  abound  m  triple  phosphates  ; 
if  detained  any  length  of  time  in  the  bladder  it  becomes  ammoniacal. 
Bacteria  are  a  frequent  cause  of  pyelitis,  as  well  as  of  abscess  of  the 
kidney,  by  migrating  from  a  diseased  bladder.  In  some  instances  of 
pyelitis  an  eruption  like  rubella  is  noticeable.  Pyelitis  not  infrequently 
affects  only  one  kidney. 

The  most  difficult  point  connected  with  the  recognition  of  pyelitis 
is  the  ascertaining  that  the  purulent  discharge  does  not  proceed  from 


THE  URINE,  AND  DISEASES  OF  THE   URINARY  ORGANS.     705 

the  bladder.  And  there  is  no  positive  sign  to  guide  us,  except  tlie 
existence  in  the  urine  of  epithehum  from  the  pelvis  of  the  kidney, 
cUstinguishal3le  by  its  oval  or  fusiform  shape,  and  by  the  frequent 
occurrence,  in  a  cell,  of  clearly-defined,  dark-colored,  round  granules, 
and  of  two  nuclei.  But  this  epithelium  will  not  be  always  found,  and 
we  have  then  to  fall  back  upon  the  history  of  the  case,  upon  the 
attacks  of  renal  pain,  upon  the  hgematuria  caused  by  a  calculus,  and 
upon  the  combination  of  signs  as  pointing  more  to  one  disease  than  to 
the  other.  In  some  cases  there  is  a  perceptible  swelling  in  the  loin  ; 
at  times,  too,  owing  to  coexisting  degeneration  of  the  cortex  of  the " 
kidney,  the  amount  of  albumin  is  wholly  disproportionate  to  that  con- 
tained in  pus,  and  this  becomes  a  valuable  indication  of  the  affection 
not  being  vesical.  But  if  there  be  a  coincident  disease  of  the  bladder, 
the  differential  distinction  may  become  impossible.  Under  these  cir- 
cumstances, too,  the  acid  state  of  the  urine,  on  which  in  uncompli- 
cated cases  much  stress  may  be  laid,  is  not  apt  to  be  a  feature  to  aid 
us.  The  crystals  of  nitrate  of  urea  formed  when  nitric  acid  is  added 
to  the  urine  have  in  pyelitis  irregular  blades  or  are  in  the  shape  of 
small  feathers.^ 

Supposing  the  point  settled,  and  the  vesical  origin  of  the  pus  dis- 
proved, the  diagnosis  is  limited  to  an  inflammation  of  the  ureter,  to  an 
abscess  in  the  substance  of  the  kidney,  and  to  pyelitis.  Here  again 
the  history  of  the  case  comes  into  play.  Furthermore,  in  the  former 
of  these  affections — a  very  rare  one,  unless  associated  with  pyelitis — 
the  amount  of  pus  in  the  urine  is  very  trifling ;  in  the  second,  too,  it 
is  less  than  in  pyelitis,  except  when  the  abscess  empties  itself.  The 
pus  is  also,  as  already  indicated,  not  constant,  alternately  appearing  in 
and  disappearing  from  the  urine  ;  there  is  usually  more  obvious  swell- 
ing, although  this  is  by  no  means  always  discernible  or  even  present 
in  abscess,  and  the  abscess  is  attended  with  much  greater  constitu- 
tional disturbance.  Still,  here  again  we  must  admit  that  the  disorders 
are  sometimes  very  obscure  and  difficult  to  distinguish,  and  it  may  be 
impossible  to  discriminate  between  them  should  the  morbid  states 
coexist,  or  a  typhoid  condition  and  ursemic  fever  be  induced  by  the 
retention  of  the  urine  and  its  decomposition. 

Catarrhal  or  rheumat'w  pyelitis  is  generally  a  short  disease  which 
ends  favorably ;  so  does  the  idiopathic  pyelitis  of  the  puerperal  state, 
which  rarely  lasts  more  than  from  five  to  eight  days.  The  pyelitis 
with  retention  and  decomposition  of  urine  is  a  much  more  serious 
complaint,  and,  although  it  usually  runs  a  rapid  course,  not  having 

^  Pascallucci,  II  Morgagni,  quoted  in  Lancet,  June,  1873. 


706  MEDICAL   DIAGNOSIS. 

a  duration  of  more  than  a  week  or  two,  it  may  become  protracted. 
Pyelitis  due  to  the  irritation  of  calculi  is  apt  to  develop  into  a  chronic 
condition. 

In  tuberculous  pyelitis  the  symptoms  are  the  same  as  in  the  ordinary 
form.  The  association  with  tuberculosis  in  other  parts,  and  the  de- 
tection of  tubercle  bacilli  in  the  urine,  establish  the  diagnosis. 

In  those  cases  of  pyelitis  in  which  there  is  a  very  decided  obstruc- 
tion to  the  flow  of  urine  through  the  ureter,  caused  by  a  calculus,  a 
clot  of  blood  or  viscid  pus,  or  other  debris,  the  discharge  of  pus  is 
suddenly  arrested  and  the  cavity  of  the  pelvis  dilates  greatly ;  grad- 
ually the  gland-tissue  is  compressed,  and  a  large  pus-containing  sac  is 
formed,  giving  rise  to  a  condition  known  as  pyonephrosis^  and  to  a  dis- 
tinctly limited  swelling  in  the  side.  Tumors  of  this  kind  are  ordi- 
narily not  painful  to  the  touch,  are  indolent,  and  do  not  materially 
affect  the  general  health,  certainly  not  nearly  so  much  as  might  be  sup- 
posed. They  frecfuently  subside  gradually  by  free  discharges  of  pus, 
and  the  patient  recovers.^  Sometimes  they  become  much  reduced, 
and  then  swell  up  again  from  time  to  time.  They  may  occur  in  both 
kidneys ;  but  this  is  of  great  rarity.  The  urine  generally  contains 
albumin  and  considerable  pus  ;  it  is  acid  and  of  low  specific  gravity. 

Pyonephrosis  cannot  be  distinguished  from  suppurative  nephritis 
and  ordinary  abscess  of  the  kklney,  except  it  be  by  the  history.  The 
more  constant  and  larger  discharge  of  pus  may  be  also  made  a  point 
of  diagnosis,  as  well  as  the  obvious  variations  in  the  swelling,  and  the 
slighter  constitutional  symptoms.  But  too  much  stress  must  not  be 
laid  on  these  points ;  and  the  fact  should  not  be  overlooked  that 
abscess  of  the  kidney  may  be  latent,  or  be  present  almost  Avithout 
fever,  or  with  very  obscure  manifestations  of  pain,  irregular  attacks 
of  fever,  and  vomiting,  coming  on  at  intervals  for  months  or  years. 

When  there  is  an  impediment  to  the  flow  of  urine  the  pelvis  of 
the  kidney  dilates  from  the  accumulating  urine  and  we  have  hydro- 
nephrosis; in  time  the  kidney  tissue  disappears.  Hydronephrosis  is 
due  to  mechanical  obstruction  from  retroflexion  or  cancer  of  the 
womb,  or  from  morbid  growths  or  abscess  of  the  bladder,  or  to  con- 
genital malformation  of  the  ureter,  or  to  movable  kidney  or  to  im- 
pacted stone  in  the  ureter.  Sometimes  it  is  double  ;  it  is  much  more 
common  in  women  than  in  men.  The  swelling  to  which  it  gives  rise 
may  subside  simultaneously  with  a  sudden  and  copious  discharge  of 
urine.     When  this  symptom  is  absent,  the  diagnosis  must  be  based  on 

^  See,  for  instance,  Cases  XLVIII.  and  L.  in  Todd's  Clinical  Lectures  on  the 
Urinary  Organs. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     707 

pain  in  the  back,  frequent  micturition,  and  the  existence  of  a  fluctu- 
ating renal  tumor,  often  lobulated,  and  on  the  absence  of  signs  of  sup- 
puration. There  may  be  attacks  of  renal  colic  due  to  the  passage  of 
clots  of  blood.  The  urine  is  at  times  copious,  at  times  scant.  The 
disease  may  lead  to  temporary,  but  entire,  suppression  of  urine.  Ac- 
curate percussion  enables  us  to  distinguish  hydronephrosis  from 
ascites ;  in  the  former  the  dulness  is  generally  one-sided,  and  is  un- 
influenced by  change  of  position.  Ovarian  cysts  are  more  difficult  to 
discriminate.  Careful  examinations  by  the  rectum  and  by  the  vagina, 
and  an  investigation  of  the  fluid  after  an  exploratory  puncture,  are 
alone  of  value ;  and  even  the  latter  may  mislead.  Urinary  constitu- 
ents, for  instance,  have  been  found  to  be  absent  in  rare  cases  of  hy- 
dronephrosis. Pyonephrosis  is  chiefly  distinguished  by  the  irregular 
fever,  chills,  and  the  purulent  urine. 

Hydatid  tumor  of  the  kidney  is  of  comparatively  rare  occurrence, 
and  is  likely  to  be  confounded  with  hydronephrosis.  When  the  urine 
contains  no  hydatid  vesicles  or  their  debris  and  the  hydatid  fremitus 
is  absent,  the  diagnosis  is  extremely  difficult,  and  must  rest  chiefly  on 
the  history  of  the  case. 

Ordinary  renal  cysts,  when  large  enough  to  occasion  a  tumor,  can- 
not be  distinguished  from  hydronephrosis  save  by  the  history,  and 
by  the  albuminous  and  decidedly  bloody  urine  which  the  cysts  give 
rise  to,  while  in  hydronephrosis  the  urine  presents  nothing  peculiar, 
or  occasionally  only  small  amounts  of  pus  and  of  blood.  Then,  renal 
cysts  are  double-sided,  preserve  the  shape  of  the  kidney,  and  do  not 
rapidly  change  their  size.  There  are  casts  in  the  urine,  and  the  gen- 
eral symptoms  are  those  of  chronic  interstitial  nephritis  including  the 
cardio-vascular  changes. 

Pyelitis  may  be  connected  with  fibrinous  clots  due  to  repeated 
hemorrhages  from  multiple  aneurisms  of  the  renal  artery.  We  may 
suspect  this  condition  if  the  other  more  usual  causes  of  pyelitis  seem 
to  be  absent,  and  if  the  affection  happen  in  an  old  person  having  re- 
peated attacks  of  hasmaturia  and  atheromatous  arteries.^ 

Disorders  in  which  a  very  large  Amount  of  Urine  is  dis- 
charged. 

Diabetes. — In  diabetes  mellitus,  or  glycosuria,  the  urine  is  of  pale 
color,  decidedly  acid,  and  of  high  specific  gravity,  ranging  generally 
from  1030  to  1050.  The  quantity  passed  is  enormous  :  seventy  pints 
and  upward  have  been  known  to  be  discharged  daily.     The  urea  is 

^  Ollivier,  Archives  de  Physiolof,ne,  1873. 


708  MEDICAL   DIAGNOSIS. 

increased ;  so  are  the  sulphates,  the  chlorides,  and  the  earthy  phos- 
phates, while  the  alkaline  phosphates  vary  greatly  with  the  food,  and 
uric  acid  is  diminished ;  so  is  the  coloring-matter.  The  urine  contains 
from  one  to  ten  per  cent,  of  sugar.  In  a  small  proportion  of  cases  the 
flow  of  urine  is  not  increased,  nor  is  the  specific  gravity  above  nor- 
mal.    In  some  instances  the  phosphates  are  strikingly  in  excess. 

The  symptoms  attending  the  drain  of  fluid  from  the  system  are 
great  thirst,  constipation,  a  dry,  harsh  skin,  a  red  tongue,  and  a  feel- 
ing of  constant  emptiness  and  of  hunger.  To  these  are  added  a 
steadily  progressing  waste  of  the  body,  muscular  feebleness,  chills,  a 
somewhat  hurried  breathing,  a  peculiar  mawkish  odor  of  the  breath, 
peevishness  of  temper,  chronic  catarrh  of  the  stomach,  a  tendency  to 
eczema  and  to  boils  and  carbuncles,  and  in  women  pruritus  of  the 
vulva.  The  temperature  is  subnormal,  often  not  over  96°.  The  knee- 
jerk  is  generally  absent.  Cataract  and  other  defects  of  vision  are  not 
infrequent.  There  is  a  peculiar  form  of  retinitis  ;  ^  retinal  hemorrhage 
and  palsies  of  the  muscles  of  the  eyeball,  diabetic  hypermetropia,  and 
atrophy  of  the  optic  nerves  have  also  been  noticed.  Defects  in  ac- 
commodation are  common.  Diabetic  endocarditis  also  happens,  and 
is  more  frequent  in  women  than  in  men ;  ^  and  arteriosclerosis,  neu- 
rites  and  neuralgias,  periostitis,^  and  arthritic  disorders*  may  have 
their  origin  in  diabetes.  Double  sciatica  is  often  of  diabetic  source  ; 
and  there  are  cases  presenting  symptoms  like  those  of  tabes,  with 
lightning  pains  and  loss  of  knee-jerk. 

Diabetes  is  generally  a  fatal  disease  ;  yet  it  is  impossible  to  foretell 
its  exact  mode  of  termination.  Some  are  cut  off  rather  suddenly  ; 
others  drag  out  a  long  existence,  and  die  worn  out  and  dropsical,  or 
of  cirrhosis  of  the  liver,  or  of  chronic  nephritis,  or  of  broncho-pneu- 
monia, or  of  phthisis.  For  some  days,  or  even  for  weeks,  before 
death,  the  sugar  may  disappear  from  the  urine.^  Diabetic  gangrene 
is  also  a  mode,  though  not  a  frequent  one,  of  termination  of  the 
disease.^ 

When  the  disease  ends  suddenly,  it  is  apt  to  do  so  by  so-called 
diabetic  coma.     The  comatose  condition  is  prone  to  be  preceded  by 

1  Galezowski,  Compte-Rendu  du  Congres  Ophth.  de  Paris,  1862. 

2  Lecorche,  Arch.  Gen.  de  Med.,  June,  1882  ;  Bulletin  de  I'Acad.  de  Med.,  1880. 

3  Arch.  Gen.  de  Med.,  Feb.1882,  and  Amer.  Journ.  Med.  Sci.,  April,  1882. 
*Dyce  Duckworth,  St.  Barth.  Hosp.  Rep.,  vol.  xviii.,  1882. 

^  In  a  case  for  a  long  time  under  my  charge,  in  which  the  diabetes  lasted  for 
several  years,  sugar  entirely  disappeared  from  the  urine  as  the  signs  of  phthisis 
became  fully  developed,  for  some  months  before  death. 

«  See  cases  collected  by  Hunt,  Transact.  Phila.  Co.  Med.  Soc,  Nov.  1888. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     709 

vomiting  and  abdominal  pain,  rapid  pulse,  great  anxiety  and  restless- 
ness, labored  breathing,  depressed  body-heat,  headache,  and  drowsi- 
ness. These  symptoms  are  attributed  to  the  poisoning  of  the  body 
by  the  development  of  acetone,  a  derivative  of  acetic  acid,  in  the 
blood ;  the  acetone  can  be  found  in  the  urine,  and  may  be  readily 
detected  on  the  breath  by  its  odor  resembling  that  of  chloroform. 
The  evidence,  however,  of  the  decomposition  of  the  sugar  into  ace- 
tone, and  of  the  consequent  nervous  symptoms  called  diabetic  coma, 
is  not  conclusive.  Diacetone  was  believed  by  some  to  be  a  more 
probable  cause  ;  but  betabutyric  acid,  from  which  acetone  is  derived, 
is  now  more  generally  thought  to  be  the  caus'e  of  the  diabetic  coma. 
Certain  it  is  that  this  is  due  to  some  toxic  agent  of  extreme  acidity  in 
the  blood.  In  thirty  cases  of  diabetic  coma  examined  by  Naunyn,^ 
extreme  acidity  was  found ;  and  in  twenty-six  in  which  the  examina- 
tion was  made,  the  proof  of  the  excretion  of  large  amounts  of  oxy- 
butyric  acid  was  conclusive. 

Diabetes  is  a  disease  chiefly  of  the  upper  classes  of  society.  It  is 
very  rare  in  the  colored  race,  very  common  among  Hebrews.  It  is 
especially  found  in  neurotics  who  lead  a  sedentary  life,  and  a  con- 
nection between  gout  and  diabetes  can  be  often  traced,  as  also  be- 
tween obesity  and  diabetes.  The  disease  is  vastly  more  frequent 
in  men  than  in  women,  and  is  often  hereditary.  Mental  emotion, 
worry,  and  excessive  devotion  to  business  are  among  its  causes. 
There  is  evidence  of  its  being  contagious.  The  sugar  is  derived  from 
the  glycogen  in  the  body,  and  when  this  forms  in  excessive  quantities 
and  is  not  fully  destroyed  in  the  lungs,  it  is  excreted  by  the  kidneys. 
But  as  the  sugar-forming  function  is  not  a  simple  one,  and  various 
organs  and  structures,  such  as  liver,  pancreas,  and  nervous  system,  take 
part  in  it,  and  there  may  be  even  direct  change  of  the  food  products 
into  glycogen,  the  question  of  the  origin  of  diabetes  in  a  given  case  is 
never  an  easy  one.  Clinically  speaking,  we  are  apt  to  find  diabetes  in 
this  connection :  in  large  feeders,  especially  large  eaters  of  the  carbo- 
hydrates, with  poor  assimilative  powers ;  the  diabetics  among  the 
obese  and  the  dietetic  diabetics  mostly  belong  to  this  group ;  in  dis- 
eases of  the  liver,  especially  in  cirrhosis,  and  there  is  a  form  of  cir- 
rhosis with  enlargement  of  the  organs  and  with  pigmentation  of  the  skin 
which  is  regarded  as  peculiarly  associated  with  diabetes ;  in  diseases 
of  the  nervous  system,  such  as  tumors,  epilepsy, — in  fact,  in  most 
various  structural  as  well  as  functional  disorders  of  the  brain  or 
spinal  cord ;  in  disease  of  the  fourth  ventricle,  or  of  tumors  pressing 

1  Dinlietes  Mellilus,  p.  297,  Vienna,  1898. 


710  MEDICAL   DIAGNOSIS. 

there,  diabetes  has  been  particularly  noted ;  in  diseases  of  the  pan- 
creas. The  frequent  association  of  pancreatic  disease  or  disorder  of 
its  function  with  diabetes  is  very  evident,  and  depends  upon  the  with- 
drawal of  the  glycolytic  ferment  which  the  normal  gland  furnishes. 

In  the  diagnosis  of  diabetes  the  constancy  of  the  excretion  of  the 
grape-sugar  must  be  regarded,  and  not  merely  its  occasional  presence. 
In  mild  cases  the  amount  of  sugar  does  not  exceed  two  per  cent. ; 
in  severe  cases  we  find  from  five  to  ten  per  cent.  In  some  instances 
the  constitutional  symptoms  are  very  marked,  and  the  disease  runs  an 
acute  course.  The  sure  test  for  diabetes  is  furnished  by  the  chemical 
tests  for  grape-sugar  in  the  urine,  which  have  been  discussed  in  an 
early  part  of  this  chapter.  But  blood-tests  are  also  made  use  of,  and 
are  of  value  where  sugar  exists  in  doubtful  traces,  or  where  it  is  tem- 
porarily absent  from  the  urine.  Bremer's  ^  test  consists  in  comparing 
with  each  other  slides  smeared  with  normal  blood  and  with  the  sus- 
pected diabetic  blood,  after  having  been  heated  in  a  thermostat  to 
about  135°  C,  and  cooled  and  stained  in  a  one  per  cent,  aqueous 
solution  of  Congo-red  for  two  minutes.  The  excess  of  stain  is 
washed  off,  and  diabetic  blood  is  found  to  be  unstained  or  orange- 
stained,  while  normal  blood  shows  the  distinct  Congo-red  stain.  In 
leuksemic  blood,  however,  we  may  have  the  same  result  as  in  diabetic 
blood.  Diabetic  blood  will  turn  weak  alkaline  solutions  of  methylene- 
blue  to  yellowish  green  or  yellow,  and  Williamson  ^  has,  in  accordance, 
suggested  a  blood-test  for  diabetes  of  definite  proportion, — about  a  six 
per  cent,  solution. 

Starchy  and  saccharine  substances  increase  the  quantity  of  diabetic 
sugar.  Nay,  they  may  be  the  cause  of  a  little  sugar  appearing  in  the 
urine  of  healthy  persons.  Yet  those  in  whom  a  saccharine  state  of 
the  urine  is  readily  induced  are  in  danger  of  becoming  diabetic.  If 
we  are  in  doubt  whether  we  are  dealing  with  a  case  of  diabetes,  we 
may  follow  Seegen's  advice  and  let  the  patient  eat  heartily  of  saccha- 
rine and  sugar-forming  substances,  and  examine  the  urine  three  hours 
after  the  meal ;  if  no  sugar  then  be  found  in  the  urine,  diabetes  may 
be  excluded. 

In  the  aged,  sugar  may  be  present  in  the  urine  without  being 
attended  with  distressing  symptoms.  It  is  in  such  cases  that  we  are 
most  apt  to  meet  with  the  intermitting  diabetes  to  which  attention  has 
been  called  by  Bence  Jones.^     When  the  abnormal  ingredient  thus 

1  Medical  Record,  Oct.  1897. 

■■^  British  Medical  Journal,  1896,  vol.  ii. 

•^  Medico-Chirurgical  Transactions,  vol.  xxxviii. 


THE   URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     711 

disappears  from  the  urine,  it  is  replaced  by  uric  acid  and  by  oxalates. 
There  is  still  another  form  of  intermitting  glycosuria.  Sugar  is  found 
in  the  urine  during  the  paroxysms  of  intermittent  fever ;  but  it  vanishes 
,  during  the  intervals. 

Sugar  is  also  found  in  the  urine  in  small  quantities  in  the  obese,  or 
after  inhaling  chloroform  or  taking  chloral  or.sulphonal.  Among  the 
insane,  sugar  may  be  present  in  the  urine  without  there  being  other 
symptoms  of  diabetes,  and  without  grave  significance.^  Indeed,  this 
appearance  of  sugar  in  the  urine  from  passing  causes  or  without  other 
marked  symptoms  has  given  rise  to  the  distinction  made  by  some 
between  glycosuria  and  diabetes,  restricting  the  latter  term  to  persistent 
saccharine  urine  with  decided  symptoms.  The  temporary  glycosuria 
gets  well ;  true  diabetes  rarely  does. 

In  some  instances  we  have  diabetes  with  coexisting  albuminuria, 
and  even  with  other  evidences  of  Bright's  disease.  In  the  majority 
of  such  instances  the  degeneration  of  the  kidneys  has  happened  sub- 
sequently to  the  diabetes,  and  in  its  more  advanced  stages,  from  their 
constant  irritation  ;  but  I  have  met  with  cases  in  which  the  nephritis 
has  preceded  the  diabetes,  A  high  degree  of  fatty  kidney  or  amyloid 
kidney  has  also  been  noticed  in  connection  with  diabetes.  A  small 
amount  of  albumin  in  diabetic  urine  is  common. 

Chronic  Diuresis. — This  disease  is  otherwise  known  as  polyuria, 
or  diabetes  insipidus.  It  is  characterized  by  the  habitual  discharge  of  a 
very  large  quantity  of  urine  of  low  specific  gravity,  from  1001  to  1008, 
containing  an  excess  of  water,  but  no  sugar ;  urea  is  increased  ;  uric 
acid  is  very  deficient ;  inosite  is  often  present ;  kreatinin  may  be  ex- 
creted in  increased  quantity.  The  general  symptoms  are  much  the 
same  as  those  of  diabetes  ;  the  thirst  is  generally  extreme,  and  it  may 
happen  that  more  water  is  passed  than  is  drunk.  Most  cases  recover 
under  treatment,  except  when  dependent  upon  irremediable  lesion. 
They  sometimes  die  of  suppression  of  urine.^ 

The  cause  of  this  singular  malady  is  obscure.  We  meet  with 
polyuria  after  cerebro-spinal  fever,  or  in  connection  with  tumors  of 
the  brain,  or  with  disease  of  the  medulla  oblongata,  or  of  part  of  the 
floor  of  the  fourth  ventricle,  or  with  tumors  compressing  the  abdom- 
inal ganglia.  Lancereaux  tells  us  that  the  disorder  is  not  uncommon 
in  syphilitic  affections  of  the  nervous  centres ;  *  and  Bartholow's  ex- 
perience is  that  syphiloma  of  the  brain  is  its  most  usual  cause.    I  have 

^  Lailler,  quoted  in  Journal  of  Mental  Science,  May,  1871. 
^  Case  under  my  charge  at  the  Philadelphia  Hospital. 
•^  Sydenham  Society's  Translation,  p.  77. 


712  MEDICAL  DIAGNOSIS. 

repeatedly  encountered  the  malady  after  injuries  to  the  head/  after 
sunstroke,  or  in  persons  broken  down  with  malaria.  At  times  it  is 
seen  in  instances  simply  of  great  nervous  depression  without  organic 
disease.  It  is,  indeed,  mostly  connected  with  some  abnormal  state  of 
the  nervous  system.  It  has  been  stated  to  coexist  with  marked  excess 
of  phosphates,  and  to  be  a  phosphaturia. 

Cases  of  chronic  polyuria  differ  from  true  diabetes  by  the  low 
specific  gravity  of  the  urine,  and  the  utter  absence  of  a  saccharine 
ingredient.  Sometimes  a  state  of  diuresis  is  found  to  exist  temporarily 
during  the  removal  of  dropsical  effusions,  or  when  the  action  of  the 
skin  is  insufficient.  We  also  meet  with  apparent  cases  of  diuresis  in 
hysterical  iooi)ien  and  in  persons  who  suffer  from  incontinence  of  urine. 
In  all  such  we  can  establish  the  diagnosis  by  measuring  the  amount  of 
urine  passed  in  the  twenty-four  hours, — which  amount  may  be  large, 
but  is  not  inordinate.  In  hysteria  it  may  be  temporarily  very  large 
after  a  paroxysm,  but  is  not  persistently  so.  In  some  instances  dia- 
betes mellitus  alternates  with  diabetes  insipidus.  The  discovery  of 
an  hydraemic  centre  in  the  cerebellum,  as  well  as  the  well-known 
points  at  the  floor  of  the  fourth  ventricle,  which,  according  to  the 
exact  seat  of  puncture,  produce  increased  flow  of  urine  with  sugar  or 
without  sugar,  gives  us  the  clue  in  which  direction  to  look  for  the  ex- 
planation of  such  cases.  The  large  flow  of  urine  we  sometimes  meet 
with  in  contracted  kidney  is  known  from  hydruria  by  the  presence  of 
albumin  and  tube-casts  and  the  other  signs  of  kidney  degeneration. 
An  excessive  flow  of  urine  may  happen  in  hydronephrosis.  But  the 
antecedent  history,  the  previous  existence,  as  a  rule,  of  a  fluctuating 
tumor,  and  the  character  of  the  urine,  either  normal  or  containing  at 
times  traces  of  albumin  or  of  blood,  will  throw  light  on  the  character 
of  the  malady. 

Disorders  in  which  little  or  no  Urine  is  Discharged. 

Suppression  of  Urine. — Suppression  of  urine,  unconnected  with 
degeneration  of  the  kidney,  is  a  rare  disorder.  Yet  it  may  occur  in 
previously  healthy  persons,  or  in  the  course  of  /evers  of  low  type,  or 
in  alcoholism,  and  probably  associated  with  no  other  morbid  state 
than  congestion  of  the  kidneys.  It  is  occasionally  met  with  as  one  of 
the  freaks  of  hysteria,  or  is  caused  seemingly  by  the  irritation  reflected 
to  a  healthy  kidney  from  a  diseased  bladder. 

The  symptoms  it  occasions,  independently  of  the  absence  of  the 
discharge  of  urine,  are  drowsiness,  nausea,  vomiting,  coma,  sometimes 

^  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1875. 


THE  URINE,  AND  DISEASES  OF  THE  URINARY  ORGANS.     713 

convulsions ;  in  one  word,  the  symptoms  of  uraamic  poisoning.  The 
formidable  complaint  may  give  rise  to  marked  urinous  smell  of  the 
perspiration  and  of  the  breath,  and  to  exceeding  and  very  general 
cutaneous  hypersesthesia/  The  temperature  may  be  low,  and  remain 
so  even  if  there  be  coexisting  internal  inflammation,  or  be  above  the 
norm,^ 

Concerning  the  exact  cause  of  the  supression  we  are  often  kept 
in  the  dark  until  the  termination  of  the  malady ;  for,  unless  familiar 
with  the  antecedent  symptoms,  we  are  unable  to  determine, 'in  the 
absence  of  the  urinary  secretion,  whether  or  not  a  disease  of  the  kid- 
ney lie  at  the  origin  of  the  mischief. 

Oppolzer  tells  us  that  we  may  diagnosticate  thrombosis  of  the  renal 
vein  if  we  have  diminution  of  the  secretion  of  urine  and  its  final  sup- 
pression preceded  by  blood,  albumin,  and  casts  in  the  urine.  If  there 
be  a  history  of  severe  injury  to  the  kidney,  these  symptoms  have  a 
much  more  positive  meaning. 

Retention  of  Urine. — The  urine  retained  in  the  bladder  distends 
the  viscus  and  forms  a  swelling  in  the  hypogastrium,  discoverable 
both  by  palpation  and  by  percussion.  The  urine  is  generally  not 
wholly  kept  back,  for  a  slight  discharge  every  now  and  then  takes 
place,  or  there  is  a  constant  dribbling, — a  matter  which  in  itself  should 
suggest  the  introduction  of  a  catheter. 

Retention  of  urine,  if  soon  recognized,  is  not  a  dangerous  com- 
plaint, as  it  can  be  at  once  relieved  by  the  passage  of  a  catheter ;  but 
if  the  ailment  escape  observation,  or  be  inefficiently  dealt  with,  the 
bladder  may  burst, — though  Sir  Henry  Thompson  tells  us  that  this  is 
a  circumstance  of  exceeding  rarity, — or  the  patient  die  from  the 
absorption  of  the  noxious  urinary  ingredients. 

The  causes  which  lead  to  retention  are  various  ;  prominent  among 
them,  at  least  in  a  medical  point  of  view,  is  paralysis  of  the  bladder, 
especially  that  form  of  paralysis  which  occurs  in  low  fevers  ;  retention 
is  also  one  of  the  symptoms  of  paraplegia ;  then  inflammatory  swell- 
ing of  the  neck  of  the  bladder,  organic  stricture,  or  enlarged  prostate 
may  give  rise  to  it ;  again,  retention  or  incontinence  may  be  due  to 

^  This  was  the  most  obvious  symptom  in  a  case  under  my  care  at  the  Philadel- 
phia Hospital,  in  which  no  urine  was  secreted  for  many  days,  the  catheter  being 
repeatedly  introduced  into  the  bladder.  The  patient  recovered.  She  had,  previ- 
ously and  subsequently  to  the  attack,  vesical  catarrh.  In  a  case  reported  by  Fuller, 
St.  George's  Hospital  Reports,  vol.  v.,  the  difficulty  existed  for  eight  days  without 
occasioning  convulsions.  It  was  the  same  in  a  case  of  mine  that  lasted  eleven 
days  and  got  well. 

2  Bourneville,  Gaz.  Med.  de  Paris,  1872. 


714  MEDICAL  DIAGNOSIS. 

hysteria.  If  the  urine  be  long  retained  in  the  bladder,  it  becomes  alka- 
line, and  putrefactive  changes  occur,  and  fission  fungi,  especially  the 
micrococcus  ureae,  develop  in  great  numbers  in  the  ammoniacal  urine. 

The  disorder  is  readily  detected.  It  may  be  discriminated  from 
suppression  of  urine  by  the  existence  of  the  hypogastric  tumor,  and 
by  the  introduction  of  a  catheter, — a  means  which,  in  cases  of  doubt, 
ought  never  to  be  neglected.  Sometimes  the  abdominal  swelling  is 
so  great  as  to  lead  to  the  belief  of  the  existence  of  dropsy ;  and  the 
error  is  fostered  by  learning  that  the  patient  has  been  passing  his 
water,  and  has  a  constant  desire  to  discharge  it,  or  by  seeing  that  it 
dribbles  from  him. 

The  retention  from  paralysis  is  distinguished  from  that  due  to 
other  causes,  as  obstruction,  by  observing  that  the  catheter  enters 
readily,  and  that  the  urine  flows  out  in  a  continuous  stream,  in- 
creasing and  lessening  with  the  respiratory  movements,  but  does  not 
come  out  in  jets. 


CHAPTER   VIII. 

DROPSY. 

A  COLLECTION  of  watepy  fluid  iii  the  areolar  tissue  or  in  the  serous 
cavities  constitutes  dropsy.  Now,  dropsy  is  but  a  symptom,  and  is 
associated  with  various  disorders  ;  yet,  though  but  a  symptom,  it  is 
one  that  comprises  so  often  apparently  the  whole  complaint,  that  it 
will  be  useful  to  investigate  connectedly  the  clinical  meaning  of  its 
typical  forms. 

Dropsy,  according  to  its  Seat  and  Extent. 

Dropsies  may  be  external,  or  be  confined  to  internal  parts.  To 
the  latter  variety  belong  hydrothorax,  hydrocephalus,  and  ascites. 
External  dropsies  are  illustrated  by  anasarca  and  oedema ;  the  first,  a 
universal  accumulation  of  serous  fluid  in  the  areolar  textures  ;  the 
second,  a  localized  collection  in  the  same  structures.  Both  exliD^it 
painless  swelling  of  the  surface,  devoid  of  redness ;  a  skin  often 
stretched  and  shining,  pitting  upon  pressure,  and  retaining  for  some 
time  the  mark  of  the  finger ;  and  in  both,  the  tumid  part,  if  punctured, 
discharges  a  watery  fluid.  CEdema  is  most  commonly  perceived 
around  the  ankles  ;  the  tumefaction  of  anasarca  is  found  generally  not 
only  in  the  lower  extremities,  but  also  in  the  arms  and  in  the  face. 

Anasarca  is  usually  dependent  upon  disease  of  the  kidneys,  or  of 
the  heart.  The  swelling  rarely  shows  itself  at  all  parts  of  the  body 
at  once  ;  it  ordinarily  begins  at  the  feet  and  ankles  in  diseases  of  the 
heart,  in  the  face  in  diseases  of  the  kidney. 

CEdema  may  be  due  to  the  same  causes.  Yet  a  limited  collection 
of  fluid  is  often  the  consequence  of  a  purely  local  difficulty,  of  a  char- 
acter interfering  with  the  venous  circulation.  Thus,  the  compression 
or  obliteration  of  a  large  vein  occasions  oedema  below  the  point  of  the 
disorder.  We  see  oedema  happening  if  swollen  glands  press  upon  the 
main  vein  of  a  limb.  We  also  meet  with  it  in  the  adhesive  form  of 
venous  inflammation,  and  in  phlegmasia  alba  dolens.  In  all  of  these 
forms  the  oedema  is  one-sided,  and  there  is  little  difficulty  in  its  recog- 
nition. A  circumscribed  oedema  also  accompanies  erysipelatous  in- 
flammations of  the  skin  or  subjacent  tissues,  and  is  found  in  limbs 
the  general  nutrition  of  wliich  has  been  lowered  by  paralysis. 

715 


716  MEDICAL  DIAGNOSIS. 

When  the  external  dropsical  effusion  is  dependent  upon  a  tumor 
seated  in  an  internal  cavity  and  interfering  with  the  passage  of  the 
blood,  it  may  be  very  local  and  one-sided,  as  we  sometimes  find  in 
connection  with  abdominal  cancer ;  but  it  is  most  apt  to  be  found  on 
both  sides  of  a  portion  of  the  body,  although  more  particularly  marked 
on  one  side.  The  oedematous  extremities  exhibit  usually  also  marked 
enlargement  of  the  veins. 

Another  source  of  a  double-sided  oedema  is  anaemia.  The  serum 
collects  first  about  the  ankles.  The  absence  of  any  discoverable 
organic  affection,  the  pallid  countenance,  and  the  pearly  whiteness  of 
the  conjunctiva  are  very  significant.  A  microscopical  examination  of 
the  blood  and  a  blood-count  establish  the  diagnosis. 

A  dropsical  effusion  in  part  of  similar  origin,  but  much  more  often 
connected  with  internal  droj^sy,  especially  with  ascites,  is  the  dropsy 
we  observe  in  those  broken  down  by  malarial  poisoning.  The  state 
of  the  liver  and  spleen,  or  of  the  kidneys,  added  to  the  condition  of 
the  blood,  determines  the  greater  extent  of  the  effusion. 

Dropsy,  according  to  its  Causation. 

Having  viewed  anasarca  and  oedema  as  in  the  main  uncombined 
with  internal  dropsies,  and  as  forming  the  sole  signs  of  the  dropsical 
complaint,  let  us  now  look  at  them  when  associated  with  effusions  of 
serum  elsewhere.  The  same  remarks  will  also  apply  to  hydrothorax 
and  to  ascites,  the  meaning  of  which,  when  occurring  alone,  we  have 
inquired  into,  but  which  we  shall  here  consider  in  their  relations  to 
general  dropsy,  or  that  form  in  which  anasarca  or  oedema  coexists 
with  dropsy  of  one  or  several  of  the  large  serous  ca\dties. 

First,  let  us  examine  into  the  causes  of  general  dropsy.  The  most 
common  are  a  disease  *of  the  heart,  of  the  kidneys,  or  of  the  liver ;  so 
common,  in  truth,  that  in  every  case  of  dropsy  we  must  always  ex- 
amine these  organs  carefully.  According  as  the  dropsical  accumula- 
tion originates  in  a  morbid  state  of  these  viscera,  it  is  called  cardiac, 
or  renal,  or  hepatic. 

Cardiac  dmpsy  arises  in  consecjuence  of  the  deranged  or  enfeebled 
circulation  produced  by  a  disease  of  the  walls  and  cavities  of  the  heart, 
associated  or  not  with  a  valvular  lesion.  The  dropsy  begms  in  the 
feet  and  ankles,  being  much  influenced  by  position,  and  gradually  ex- 
tends upward ;  but  it  is  I'arely  very  obvious  in  the  face  or  upper 
extremities.  The  thighs  and  scrotum  are  sometimes  greatly  swollen, 
and  there  is  a  watery  effusion  into  the  pleural  cavities  or  into  the  pul- 
monary parenchyma.     Cardiac  dropsy  is  generally  chronic. 

Renal  dropsy  is  usually  much  more  general  than  cardiac  dropsy. 


DROPSY.  717 

It  is  often  first  noticed  in  the  face  and  eyelids.  The  proof  that  the 
dropsy  is  renal  is  furnished  by  the  presence  of  albumin  and  of  casts 
in  the  urine.  Renal  dropsy  is  very  often  acute,  attended  Avith  active 
symptoms,  and  occurs  in  the  course  of  acute  nephritis.  The  history 
frequently  points  to  exposure  to  cold  and  wet. 

Occasionally  the  dropsy  is  owing  to  an  affection  both  of  the  kidney 
and  of  the  heart ;  and  the  inc{uiry  may  arise,  which  of  the  organs  was 
primarily  disturbed  and  gave  rise  to  the  dropsy  ?  Valve-disease  makes 
the  cardiac,  simple  enlargement  of  the  heart  with  decided  amounts  of 
albumin  and  a  large  number  of  casts  especially  of  granular  character 
makes  the  renal,  view  predominant. 

Hepatic  dropsy  may,  like  the  preceding  forms,  be  more  or  less 
general ;  but  it  is  rarely  so,  unless  of  long  standing,  or  unless  there  be 
coexisting  disease  of  the  heart  or  of  the  kidneys.  The  most  usual 
kind  of  dropsy  of  liver  origin  is  abdominal  dropsy ;  indeed,  ascites  is 
frequently  looked  upon  as  constituting  a  proof  of  hepatic  disorder. 
Ascites  may  be  also  produced  by  peritoneal  tumors  or  inflammation, 
by  enlargement  of  the  spleen  or  of  the  pancreas,  or  by  the  pressure 
of  diseased  glands, — in  fact,  by  any  lesion  which  occasions  a  decided 
impediment  to  the  portal  circulation. 

Again,  it  is  possible,  though  it  is  not  often  a  cause,  that  mere  irri- 
tation of  the  areolar  tissue  will  occasion  more  or  less  general  dropsy. 
This  was  a  favorite  doctrine  of  the  older  physicians ;  and  H.  C.  Wood 
thus  explains  the  dropsy  of  arsenical  poisoning.^  Another  cause  of 
general  dropsy,  especially  of  anasarca,  is  peripheral  multiple  neuritis. 
I  have  seen  this  in  cases  in  which  the  electric  reactions,  the  absence 
of  the  knee-jerk,  the  altered  sensation,  made  the  diagnosis  clear.^ 

Besides  these  sources  of  general  dropsy,  we  may  find  deterioration 
of  the  blood,  with,  perhaps,  a  simply  enfeebled  condition  of  the  heart, 
giving  rise  to  it.  But  such  a  state  is  much  more  likely  to  occasion 
oedema,  or  anasarca,  than  general  dropsical  effusions. 

There  is  a  disease  apparently  like  anasarca,  but  unlike  in  the 
absence  of  serous  fluid  in  the  connective  tissues.  It  is  the  disease 
pointed  out  by  Sir  William  Gull  as  a  cretinoid  state,  and  called  by 
Ord  myxoidema,  consisting  in  the  progressive  invasion  of  the  connec- 
tive tissues  of  the  body  by  a  mucin-yielding  substance,  unassociated 
with  albuminuria  or  disease  of  the  heart,  but  invariably  combined 
with  destructive  change  and  decrease  of  the  thyroid  gland.  It  affects 
chiefly  adult  women,   who   present  swollen,  waxy-looking   features. 


'  Amer.  Journ.  Med.  Sci.,  July,  1871. 
^  As  in  a  case  seen  with  Dr.  Lewis  Briulon. 
45 


718  MEDICAL   DIAGNOSIS. 

with  not  infrequently  a  circumscribed  flusli  on  the  cheeks,  and  who 
are  markedly  anaemic,  and  seem  to  have  an  excess  of  subcutaneous 
fat.  The  skin  is  everywhere  thickened  and  rough,  is  devoid  of  per- 
spiration, and  the  puffy  integuments  do  not  pit,  or  pit  but  very  slightly, 
on  pressure.  The  eyelids  are  greatly  thickened  and  hang  in  folds  ; 
the  nose  is  broadened ;  the  lips  are  swollen,  as  are  the  tissues  above 
the  clavicles.  The  hands  are  often  swollen  and  misshaped,  the  nails 
are  brittle ;  there  is  loss  of  teeth  and  of  the  hair ;  the  thyroid  gland 
can  generally  not  be  felt.  The  temperature  is  below  the  normal ;  the 
excretion  of  urea  is  diminished.  The  expression  is  dull  and  heavy. 
The  movements  of  the  limbs  are  slow  and  languid ;  the  gait  is  uncer- 
tain and  awkward ;  sensation  is  impaired ;  there  is  irritability  and 
suspiciousness  of  temper,  with  increasing  hebetude,  monotonous  voice, 
slow,  drawling  speech ;  finally,  melancholia  and  aberration  of  mind 
may  supervene.  The  disease  may  be  artificially  produced  by  the  re- 
moval of  the  thyroid  gland.  It  has  been  also  noticed  after  the  long 
administration  of  iodide  of  potassium.^  In  certain  cases  the  atrophy 
of  the  thyroid  is  preceded  by  hypertrophy.^  The  disease  may  be 
preceded  or  be  attended  with  intractable  uterine  hemorrhage  without 
apparent  cause  ;  ^  bleeding  from  the  nose  and  gums  also  occurs. 

The  swelling  of  myxoedema  is  distinguished  from  the  dropsy  of 
acute  nephritis  by  affecting  the  forehead  as  well  as  the  face,  by  the 
mental  symptoms,  by  the  absence  of  decided  pitting,  by  thickening  of 
the  alee  of  the  nose,  and  by  the  results  of  the  urine  examination. 

It  is  more  difficult  to  distinguish  contraded  kidney  from  myxoe- 
dema. In  both  we  may  find  excessive  flow  of  urine  of  low  specific 
gravity,  and  a  few  hyaline  casts  associated  with  very  small  amounts 
of  albumin.  But  if  we  have  dropsy  in  contracted  kidney,  it  is  in  the 
lower  extremities.  Then,  the  skin  is  not  dry  and  desquamating,  and 
there  is  not  the  physiognomy  nor  the  state  of  mind  of  myxoedema. 

Adiposa  dolorosa^^  a  disease  described  by  Dercum,  differs  from 
myxoedema  in  the  irregular  and  painful  fatty  masses  not  being  found 
on  the  face,  hands,  and  feet,  and  in  the  absence  of  mental  and 
psychical  phenomena. 

^  Stalker,  Lancet,  Jan.  1891. 
^  Ord,  quoted  in  Sajous's  Annual,  vol.  iv.,  1891. 
=5  Kirk,  Lancet,  Sept.  1893. 

*  University  Med.  Mag.,  Dec.  1888,  and  TAventieth  Century  Practice,  vol.  xi. 
See  also  Eshner,  Phila.  Med.  Journ.,  Oct.  1898  ;  Spiller,  Med.  News,  Feb.  1898. 


CHAPTER    IX. 

DISEASES   OF   THE    BLOOD-VESSELS. 

Only  a  short  description  of  these  will  be  here  given,  since  many 
have  been  already  mentioned  in  connection  v^ath  other  maladies,  and 
our  knowledge  of  others  is  still  pathological  rather  than  clinical. 

Diseases  of  the  Arteries. 

The  principal  of  these  are  inflammation  and  atheromatous  changes. 

Arteritis. — Inflammation  may  attack  the  outer  coat,  periarteritis, 
the  inner  coat,  endarteritis,  or  all  the  coats,  general  arteritis.  All  these 
processes  may  be  the  result  of  rheumatism,  of  gout,  of  syphilis,  of 
lead  poisoning,  of  infective  maladies,  or.  of  inflammation  spreading 
from  surrounding  textures. 

In  periarteritis  the  last-named  is  the  most  common  cause.  The 
large  arteries  are  the  ones  that  are  pre-eminently  affected,  and  inflam- 
mation of  the  external  coat  of  the  thoracic  aorta  is  more  often  encoun- 
tered than  that  of  any  other  artery.  It  may  be  acute  ;  occasionally  it 
has  its  origin  in  inflammation  of  the  inner  coat.  It  may  lead  to  sup- 
puration, and,  the  pus  fmding  its  way  into  the  caliber  of  the  vessels, 
pyaemia  and  metastatic  abscesses  are  caused.  But  it  is  not  possible  to 
make  a  certain  diagnosis  of  the  condition. 

There  is  a  peculiar  disease  of  the  arteries,  periarteritis  nodosa, 
which,  with  the  signs  of  acute  desquamative  nephritis  and  fever  and 
marked  anaemia,  gives  rise  to  numbness,  to  rapid  loss  of  muscular 
power  with  deficient  electro-muscular  contractility,  and  to  such  severe 
muscular  pains  that  they  are  really  mistaken  for  those  of  trichiniasis. 
But  the  history  of  the  ailment,  the  signs  of  the  thickening  of  the 
vessels,  the  little  nodules  under  the  skin,  if  discernible,  the  violent 
paroxysmal  pains  in  the  hypochondrium,  the  spreading  paralysis, 
starting  from  the  fingers  as  the  malady  advances,  and  the  rapid  pulse 
with  the  comparatively  low  temjjcrature,  throw  light  on  the  cause  of 
the  muscular  distress.     The  disease  is  rapidly  fatal. 

Endarteritis  is  almost  always  chronic,  and  chronic  endarteritis  is 
most  commonly  due  to  rheumatism,  to  gout,  to  syphilis,  to  alcohol,  to 
the  poisonous  influence  of  lead  or  of  arsenic,  to  altered  quality  of  the 
blood,  or  is  seen  in  connection  with  contracted  kidney.     As  regards 

719 


720  MEDICAL  DIAGNOSIS. 

the  latter,  the  question  may  arise  as  to  whether  it  has  caused  the 
change  in  the  arteries  or  is  a  mere  coexisting  affection  owing  to  the 
same  general  morbid  process,  a  fibrosis.  Arthur  V,  Meigs  ^  urges  this 
view,  and  I  believe  it  is  generally  the  true  explanation.  It  is  certain 
that  chronic  endarteritis  is  found  without  Bright's  disease,  or  preceding 
it,  and  gives  rise  to  symptoms  by  which  it  can  usually  be  recognized. 
It  is  commonly  described  as  arteriosclerosis,  in  consequence  of  the 
hardening  of  the  avails  of  the  artery,  and  its  most  usual  kind,  the 
senile  form,  is  noted  after  the  age  of  fifty  as  a  degenerative  change. 
Thickening  of  the  intima  is  the  most  common  disease  of  arteries,  and 
may  lead  to  obliterative  endarteritis .- 

The  thickening  of  the  intima  of  the  arteries  and  arterioles  may 
extend  to  some  degree  into  the  veins.  The  symptoms  to  which 
chronic  endarteritis  gives  rise  are  increased  blood-pressure,  head- 
ache, cold  extremities,  breathlessness  on  exertion,  ana?mia,  epistaxis, 
or  hemorrhages  into  internal  organs,  such  as  the  brain  or  the  lungs ; 
oedema  without  recognizable  cause ;  attacks  of  bronchitis  or  catarrhal 
pneumonia ;  and  torpor  of  the  liver.  An  appearance  of  prominence 
of  the  smaller  vessels  and  their  greater  resistance  show  the  fully 
developed  disease,  and  we  then  find  nervous  symptoms,  such  as 
vertigo,  at  times  with  syncope,  loss  of  memorj^  and  general  want  of 
power  in  the  limbs.  Hypertrophy  of  the  heart,  fibroid  heart,  and,  at 
times,  dilatation  and  valve-changes  may  also  be  present,  as  well  as 
albumin  and  casts  in  the  urine,  and  other  signs  of  kidney  affection. 
But  these  do  not  necessarily  occur.  Again,  there  are  cases  in  which 
they  seem  to  precede  the  endarteritis.  The  visceral  complications  of 
the  malady  make  statements  about  the  temperature  uncertain,  but  I 
beUeve  that  it  is  persistently  slightly  elevated.  Endarteritis  is  at  times 
compensatory  in  slowing  of  the  blood-current.^  An  accentuation  of 
the  second  sound,  as  well  as  its  reduplication,  is  a  usual  feature  in 
arteriosclerosis.  In  arteriosclerosis  of  the  coronary  arteries  the  pulse 
is  slow  or  irregular,  and  angina  pectoris  is  common. 

Extensive  inflammation  of  the  arteries,  a  general  arteritis,  is  a  very 
rare  affection,  and  when  it  happens  it  is  acute.  In  a  few  instances  of 
rheumatism  we  find  acute  arteritis  arising,  and  especially  inflammation 
of  the  fibrous  structures  of  the  aorta.  This  condition  may  be  sus- 
pected should  we  observe  intense  general   uneasiness  and   distress, 

1  Transactions  College  of  Physicians  of  Philadelphia,  1888  and  1889,  and  the 
Origin  of  Disease,  Philadelphia,  1897. 

^  The  changes  by  which  this  is  brought  about  are  admirably  shown  in  Meigs's 
•work  on  the  Origin  of  Disease. 

^  Thoma,  Virchow's  Archiv,  April,  1888. 


DISEASES  OF  THE   BLOOD-VESSELS.  721 

with  pain,  increased  pulsation,  a  distinct  murmur  in  the  course  of  the 
vessel,  and  tumultuous  action  of  the  heart  without  there  being  obvious 
signs  of  disease  of  that  organ  present.  Still,  the  diagnosis  is  never  a 
positive  one.  We  may  also  meet  with  arteritis  clearly  infective,  and 
general  or  local,  in  influenza,  in  pneumonia,  in  typhoid  fever,  and  in 
ulcerative  endocarditis.  The  result  of  the  inflammation  is  that  the 
blood  may  clot,  and  thrombi  or  emboH  result,  and,  if  infected,  pysemic 
fever  develop.  It  is  generally  impossible  to  recognize  the  malady  until 
after  the  thrombosis ;  and  then  severe  pain  in  the  limb  supplied  by 
the  affected  vessel,  its  sensitiveness  and  cord-like  feel,  the  absent 
pulse  and  the  coldness  of  the  skin  and  lowered  local  temperature, 
and  the  swelling  of  the  part  are  significant  of  a  condition  that  often 
ends  in  gangrene.  Yet  all  these  signs  of  narrowing  of  the  caliber  of 
a  vessel  may  occur  without  a  thrombus,  and  be  due  to  proliferating 
endarteritis,  such  as  may  exist  in  obliterative  endarteritis. 

Atheromatous  Changes. — These  are  only  the  more  obvious 
naked  eye  appearances,  especially  as  they  are  found  in  the  aorta  and 
larger  vessels,  due  to  arteriosclerosis ;  calcareous  degeneration  is 
often  seen.  These  alterations,  happening  in  internal  arteries,  are  be- 
yond the  accurate  discernment  of  the  physician.  He  may  infer  that 
they  exist,  if  a  distinct  systolic  blowing  sound  be  heard  in  the  track 
of  the  aorta  or  its  branches,  in  a  person  who  is  not  markedly  anaemic, 
who  is  past  middle  life, — and  therefore  at  an  age  at  which  these  kinds 
of  changes  of  tissue  happen, — or  has  had  any  of  the  diseases  predis- 
posing to  arteriosclerosis,  and  in  whom  no  cardiac  murmurs,  or  only 
faint  cardiac  murmurs,  are  perceived.  But  it  is  chiefly  by  the  age  of 
the  patient,  the  rigid  resisting  superficial  arteries,  often  irregular  to  the 
touch,  and  the  gradual  development  of  cardiac  enlargement,  that  a 
conclusion  as  to  the  meaning  of  the  physical  signs  is  arrived  at. 
The  atheromatous  change  may  be  so  great  as  to  cause  almost  com- 
plete occlusion,  even  in  arteries  as  large  as  the  common  carotid. 

Diseases  of  the  Veins. 

The  chief  affection  of  the  veins  in  a  diagnostic  point  of  view  is 
inflammation. 

Phlebitis. — This  is  met  with  by  the  surgeon  much  oftener  than 
by  the  physician,  who  encounters  it  more  especially  in  affections  of 
internal  organs,  such  as  the  liver,  and  has  to  study  it  in  association 
with  the  formation  of  thrombi,  and  metastatic  abscesses  to  which 
it  leads,  and  with  infective  fevers.  The  most  common  form  in 
which  phlebitis  comes  under  the  cognizance  of  the  physician  is  in 
connection  with  milk  leg,  ov  phlegmasia  alba  dolens.     Here  we  liave 


722  MEDICAL   DIAGNOSIS. 

usually  phlebitis  with  an  obstruction  by  a  coagulum  of  the  venous 
circulation  in  the  affected  limb,  and  bacilli,  those  of  typhoid  fever  for 
instance,  have  been  detected  both  in  the  clots  and  in  the  walls  of  the 
vessels.  Yet  it  is  by  no  means  certain  that  the  thrombosis  is  always 
secondary  and  caused  by  phlebitis.  The  phlebitis  or  the  thrombus 
that  forms,  when  of  septic  origin,  may  lead  to  pysemia.  The  disease, 
except  in  gouty  phlebitis,  is  mostly  one-sided.  The  pain  in  the  leg 
may  cause  it  to  be  mistaken  for  rheumatism,  but  the  one-sided  swell- 
ing and  the  oedema  distinguish  it.  Among  its  early  and  significant 
symptoms  is  pain  on  pressing  the  calf  of  the  leg  on  the  affected  side. 

Diseases  of  the  Capillaries. 

Some  of  the  organic  diseases  of  the  capillaries  belong  to  the  arterio- 
sclerosis in  Bright's  disease,  or  to  the  waxy  degeneration  in  purpura. 
It  is  difficult  to  say  what  the  functional  disorders  are,  for  many  of 
them  are  regarded  as  forming  part  of  the  peripheral  diseases  of  the 
nervous  system,  and  the  affection  of  the  arterioles  and  of  the  capil- 
laries is  a  mere  vasomotor  spasm  in  connection  with  the  neurosis. 
This  is  supposed  to  be  the  case  in  the  anomalous  localized  sensations 
of  cold  which  some  patients  have  in  particular  parts  of  the  body, 
though  their  persistency  is  unlike  a  spasm.  The  painful  flushings  of 
the  feet  bespeak  temporary  excessive  dilatation  of  the  fine  vessels. 

A  spasm  of  the  minute  vessels  of  more  permanent  character  may 
lead  to  profound  disturbance  of  nutrition  in  a  part,  even  to  its  de- 
struction. This  is  the  case  in  the  vasomotor  neurosis,  called  symmet- 
rical gangrene^  or  "Raynaud's  disease." 

The  affection  shows  itself  in  three  forms,  local  syncope,  local 
asphyxia,  and  symmetrical  gangrene,  which  are  in  reality  but  different 
stages  of  a  condition  in  which  there  is  recurring  contraction  of  the 
arterioles  and  consequent  interference  with  nutrition.  The  malady 
is  most  often  seen  in  the  hands  affecting  corresponding  fingers ;  it  is 
also  met  with  in  the  feet,  on  the  exterior  surface  of  the  forearm,  and 
sometimes  in  the  helix  of  the  ear,  on  the  nates,  the  front  of  the 
thighs,  and  below  the  knees.  It  is  nearly  always  symmetrical.  The 
local  syncope  shows  itself  mainly  in  sudden  attacks  of  pallor,  cold- 
ness and  numbness  of  corresponding  fingers,  and  in  these  "  dead 
fingers"  there  is  a  cramp-like  pain  and  impairment  of  tactile  sense 
and  of  sensibility  to  pain ;  the  surface  temperature  is  lowered.  The 
attacks  are  apt  to  come  on  at  the  same  hour,  often  in  the  morning, 
and  may  recur  daily  for  some  months.  They  are  more  common  in 
winter  than  in  summer,  are  readily  brought  about  by  exposure  to 
cold  or  by  putting  the  hands  in  cold  water,  and  are  especially  met 


DISEASES  OF  THE  BLOOD-VESSELS.  723 

with  in  hysterical  women  and  in  neurasthenics.  Each  attack  lasts 
from  a  few  minutes  to  several  hours  ;  in  the  reaction  the  skin  be- 
cofnes  red  and  sensitive  to  pressure.  In  local  asphyxia  we  have  the 
same  history,  but  duskiness  is  soon  noted,  and  purple  or  bluish  dis- 
coloration of  the  symmetrically  affected  parts.  There  is  much  pain 
in  them,  and  difficulty  in  executing  concerted  movements.  The 
paroxysm  gradually  passes  away ;  at  times  there  are  coexisting  tem- 
porary alterations  in  the  fundus  of  the  eye.  In  symmetrical  gangrene 
there  may  have  been  preceding  local  syncope  or  asphyxia,  but  these 
have  become  very  frequent,  and  the  altered  nutrition  shows  itself  in 
bullEe  forming,  and  then  in  limited  gangrene,  as  of  the  tip  of  a  finger, 
which  slowly  sloughs  off ;  within  ten  days,  generally,  the  gangrenous 
process  is  over. 

The  local  character  of  the  lesions,  their  intermittency,  and  their 
superficiality,  are  the  chief  features  of  Raynaud's  disease.  We  do 
not  find  lesions  of  the  vessels  as  in  senile  gangrene.  The  malady  is 
closely  allied  to  paroxysmal  hEemoglobinuria,  which,  indeed,  has  been 
repeatedly  observed  in  association. 

Raynaud's  disease  must  not  be  mistaken  for  chilblains.  These  do 
not  appear,  disappear,  and  reappear  in  the  manner  in  which  the  dis- 
coloration does  in  Raynaud's  disease. 

In  erythromelalgia,  described  by  Weir  Mitchell,^  there  are  vascular 
changes,  acute  congestion,  or  cyanosis.  The  disorder  manifests  itself 
in  one  or  more  extremities,  usually  in  the  heel  or  the  sole  of  the  foot, 
and  is  attended  with  flushing,  local  fever,  and  great  pain,  which 
comes  on  in  paroxysms,  aggravated  by  the  vertical  position  and  by 
movement.  It  is  an  affection  of  middle  life,  of  which  the  pathology 
is  still  undetermined.  It  resembles  most  closely  Raynaud's  disease. 
But  contrasting  Wei?-  MitcheWs  disease  with  this,  we  find  these  striking 
differences  :  there  is  in  erythromelalgia  no  change  of  color  until  the 
part  hangs  down,  when  it  becomes  rose-red.  Then,  too,  the  pain 
becomes  worse,  as  it  also  does  in  summer  and  by  heat,  whereas 
neither  position  nor  season  affects  the  local  asphyxia  of  Raynaud's 
disease,  though  cold  is  very  apt  to  produce  it.  Moreover,  in  this  there 
is  lowered  local  temperature  and  anaesthesia  to  touch  and  pain,  whereas 
increased  heat  of  the  flushed  part,  undisturbed  sensation,  and  hyper- 
algesia mostly  occur  in  Weir  Mitchell's  disease.  Further,  this  is  gen- 
erally symmetrical,  and  never  associated  with  a  local  gangrene,  such 
as  often  follows  the  local  asphyxia  of  Raynaud's  disease. 

'  Medical  News,  Aug.  1893. 


CHAPTER   X. 

DISEASES   OF   THE   BLOOD. 

Prominent  among  the  clinical  traits  of  all  diseases  of  the  blood  are 
general  debility,  a  changed  aspect  of  the  mucous  membranes  and  of 
the  skin,  especially  in  color,  and  alterations  of  nutrition.  In  the 
investigation  of  these  diseases,  the  microscope  is  of  the  first  impor- 
tance. It  informs  us  with  regard  to  the  relative  proportions  of  the 
white  and  red  corpuscles,  and  exhibits  the  blood-plates  or  hsemato- 
blasts.  It  tells  us  much  as  to  what  part  of  the  blood-making  organs 
the  former  are  derived  from,  and  which  are  purely  pathological ;  it 
indicates  whether  the  red  globules  are  of  the  right  color,  whether 
their  outline  is  regular,  and  whether  their  number  is  altered.  It 
enables  us  to  study  the  blood-films  and  the  effects  on  them  of  various 
stains. 

To  count  the  blood-corpuscles,  the  forms  of  apparatus  now  mostly 
in  use  are  the  hsemocytometer  of  Thoma-Zeiss  and  of  Gowers.  An- 
other is  the  graduated  moist-chamber  globule-counter  of  Malassez ; 
another  the  haematokrite. 

The  Thoma-Zeiss,  or  Zeiss,  hgemocytometer  consists  of  three  parts  : 
a  graduated  pipette  or  mixing-vessel,  with  rubber  tube  attached ;  a 
counting-cell  on  an  object-slide  made  of  ground  glass  ;  a  cover-glass 
with  ground  level  surfaces. 

To  count  the  red  corpuscles  of  the  human  blood,  the  tip  of  the 
fmger  should  be  thoroughly  cleaned,  the  middle  finger  of  the  left 
hand  being  generally  selected.  By  rubbing  the  end  of  the  fmger  or 
the  lobe  of  the  ear  with  a  coarse  towel  a  slight  hyperaemia  is  induced, 
so  that  a  cut  with  a  spear-pointed  needle  will  permit  of  the  flow  of 
a  drop  of  blood  sufficiently  large  for  examination.  The  tip  of  the 
pipette  is  placed  into  this  drop,  and  the  blood  carefully  drawn  up  to 
the  mark  1, — i.e.,  one  cubic  millimetre.  After  this  has  been  accom- 
plished, the  tip  should  be '  cleaned  by  means  of  a  soft  cloth  and  the 
pipette  inserted  into  a  carefully  filtered  ten  per  cent,  solution  of  sodium 
sulphate,  or  Thoma's  substitute  of  a  three  per  cent,  solution  of  sodium 
"chloride,  or  Gowers's  solution  of  112  grains  of  sulphate  of  sodium  in 
5  drachms  of  acetic  acid  and  4  ounces  of  water.     This  is  drawn  up 

724 


DISEASES  OF  THE  BLOOD.  725 

into  the  tube  until  the  bulb  is  filled  to  the  mark  101.  The  blood  and 
fluid  are  then  mixed  by  shaking  the  tube,  holding  the  finger  over  the 
tip  of  the  pipette,  that  the  liquid  may  not  escape.  After  the  mixture 
has  been  thoroughly  effected,  half  of  the  fluid  in  the  bulb  is  blown 
out,  and  the  drop  that  follows  is  permitted  to  flow  on  to  the  pre- 
viously cleaned  floor  of  the  counting-cell.  The  cover-glass  is  then 
immediately  placed  in  position,  and  the  apparatus  allowed  to  stand 
upon  a  horizontal  surface  for  two  or  three  minutes,  that  the  corpuscles 
may  settle.  For  the  success  of  this  operation  perfect  cleanliness  must 
be  maintained. 

In  order  to  make  the  examination,  the  slide  should  be  placed  in 
the  stand  of  the  microscope  and  held  in  a  horizontal  position,  that  the 
corpuscles  may  not  be  displaced.  Great  care  should  be  taken  that  no 
liquid  flow  between  the  cover-glass  and  the  ring.  It  is  important  that 
the  drop  of  blood  mixture  shall  remain  standing  in  the  centre  of  the 
cell,  and  that  by  the  spreading  of  the  cell  the  under  surface  of  the 
cover-glass  shall  be  in  contact  with  the  mixture  for  several  millimetres. 
Using  a  one-fourth  or  a  one-fifth  objective  glass  to  bring  into  view  the 
divisions  cut  upon  the  floors  of  the  cell,  we  find  that  upon  these  lie 
the  red  blood-corpuscles.  The  number  of  corpuscles  in  each  space 
is  then  noted,  counting  in  the  corpuscles  touching  the  top  and  right 
lines,  but  leaving  out  those  touching  the  lower  and  left  lines.  Through 
each  fifth  horizontal  and  vertical  row  of  the  lines  an  additional  line  is 
drawn,  for  the  purpose  of  fixing  more  readily  the  position  of  the 
squares  counted. 

Each  field  of  the  net-work  contains  a  surface  of  one  four-hun- 
dredth of  a  square  millimetre.  The  distance  of  the  cell-floor  from 
the  under  surface  of  the  cover-glass  is  one-tenth  of  a  millimetre. 
Each  scjuare,  therefore,  represents  the  one  four-thousandth  of  a  cubic 
millimetre.  The  number  of  corpuscles  contained  in  one  of  these  cells 
multiphed  by  the  number  of  times  the  blood  has  been  diluted  will 
give  the  amount  of  corpuscles  contained  in  the  one  four-thousandth 
of  a  cubic  millimetre.  The  amount  contained  in  a  cubic  millimetre 
can,  therefore,  be  found  by  multiplying  by  four  thousand.  The  surest 
method  is  to  count  at  least  thirty-six  spaces,  as  Cabot  ^  does,  or  forty 
spaces,  to  take  the  average  of  them  all,  and  proceed  as  above.  It  is 
sometimes  difficult  to  distinguish  the  white  from  the  red  blood-cor- 
puscles, and  this  difficulty  is  obviated  by  adding  a  one-third  per  cent, 
solution  of  acetic  acid  to  the  diluted  blood.  Another  method  for  com- 
puting the  white  corpuscles  and  their  relative  number  to  the  red  is  to 

1  Clinical  Examination  of  the  Blood,  1898. 


726 


MEDICAL  DIAGNOSIS. 


Fig. 


use,  with  the  salt  solution,  a  few  drops  of  a  one  per  cent,  solution  of 
gentian  violet ;  this  leaves  the  red  blood-corpuscles  unaltered  and 
stains  the  leujcocytes  a  deep  violet ;  or  we  may  employ  Toisson's 
solution,  which  consists  of  methyl  violet,  5B,  0,25  gm. ; 
chloride  of  sodium  1000  gms.,  sulphate  of  sodium  8000 
gms.,  neutral  glycerin  30,000  cms.,  and  distilled  water 
160,000  cms.  It  takes  about  ten  minutes  to  fully  stain 
the  leucocytes. 

The  following  method   for  differential  counting  of 
leucocytes  in  fresh  blood  is  recommended  by  Elzholz. 
ifter  drawing  blood  into  the  pipette,  a  solution  com- 
posed of  seven  grammes  of  two  per  cent,  eosin  solution, 
forty-five  grammes  of  glycerin,  and  fifty-five  grammes 
)f  water  is  added ;  then,  a  solution  composed  of  four 
Irops  of  concentrated  watery  solution  of  gentian  violet 
vith  one  drop  of  absolute  alcohol  and  fifteen  grammes 
of  water,   by  which  the   polynuclear   c»lls   are   more 
leeply  stained ;  the  eosinophile  cells  are  reddish  violet. 
The  hcemocytometer  of  Gowers  is  about  the  same  as 
Ihat  of  Zeiss,  differing  mainly  in  the  number  of  divisions 
)n  the  cell,  each  space  being  but  one-tenth  of  a  milli- 
metre in  length.     The  method  of  preparing  the  blood 
olution  is  not  so  convenient  as  that  of  Zeiss,    A  hsemic 
unit  of  five  millions  of  corpuscles  to  one  cubic  milli- 
metre of  blood  is  assumed.     The  pipette  is  best  cleaned 
\dth  an  aspirator.     In  the  hsemocytometer  of  Durham^ 
the  pipette  is  self-filling. 

By  the  original  method  of  Malassez  the  blood  is 
diluted  with  artificial  serum  so  that  it  represents  j^-^  or 
2^0^  of  the  original,  A  small  amount  is  then  introduced 
into  a  flattened  capillary  tube  of  known  capacity  and, 
with  the  micrometer  eye-piece,  the  globules  are  counted 
in  the  capillary  tube  of  a  certain  length,  say  500  micromillimetres. 
The  capacity  of  this  length  of  the  tube  in  parts  of  a  cubic  millimetre 
being  already  known,  the  entire  number  of  globules  in  a  cubic  milli- 
metre of  the  undiluted  blood  is  easily  determined  by  calculation.  For 
the  purpose  of  diluting  the  blood  ^  Potain's  capillary  pipette  (Fig,  68) 
is  well  adapted. 


Potain's  pipette. 


^  Coles,  Edinburgh  Medical  Journal,  Oct.  1897. 

'■^  Malassez  recommends  for  artificial  serum  a  five  or  six  per  cent,  solution  of 
sodium  sulphate,  having  a  specific  gravity  of  1020  to  1024. 


DISEASES  OF  THE  BLOOD. 


727 


The  use  of  the  hEemocytometer  in  any  form  requires  skill  and 
patience,  and  even  with  great  care  the  counts  give  between  two  and 
four  per  cent,  of  error.  To  save  time  and  prevent  the  eye-strain,  Hedin,^ 
in  1890,  devised  the  hcematokrite,  by  which  the  entire  mass  of  the  glob- 
ules in  a  definite  quantity  of  blood  can  be  rapidly  ascertained.     The 


Fig.  69. 


Blood-mixture  as  seen  with  the  square  micrometer  ruUng  of  the  moist-chamber  of  Malassez  ;  mag- 
nified 250  diameters. 

instrument  consists  of  a  capillary  glass  tube,  correctly  graduated,  in 
which  a  certain  volume  of  diluted  blood  is  held,  while  the  tube  is 
subjected  to  centrifugal  action,  by  which  the  separation  of  the  plasma 
and  the  cellular  elements  is  effected.  The  proportion  is  determined 
by  the  scale  engraved  upon  the  side  of  the  glass  tube,  and  the  globu- 
lar richness  of  the  blood  is  promptly  determined.  The  original  m- 
strument  of  Hedin  has  been  advantageously  mochlied  by  Gartner,^ 
Arnold,^  and  especially  Daland.^ 


^  Scandinavisches  Archiv  fiir  Physiologic,   No.  2,  134 ;  Prager  Med.  Wochen- 
schrift,  1891. 

^  Berliner  klinische  Wochenscluift,  1893,  No.  4. 

3  Medical  News,  Sept.  29,  1894,  p.  348. 

*  Transactions  of  the  College  of  Physicians  of  Philadelphia,  May  2,  1894. 


728 


MEDICAL  DIAGNOSIS. 


The  instrument  of  Daland  is  arranged  to  carry  two  glass  tubes, 
the  outer  ends  of  wliich  fit  into  small,  cup-like  depressions.  Each 
tube  measures  fifty  millimetres  in  length,  ^vith  a  lumen  of  half  a  mil- 
limetre, and  upon  it  is  a  scale  representing  on-e  hundred  equal  parts ; 
a  lens  front,  by  magnifj-ing  the  column  of  hlood,  facilitates  the  reading 


Fig. 


Dala^li's  BLematokeite. — The  central  cut  represents  the  complete  instrument,  vrith  revolving 
tubes  in  ]X)sition.  To  the  left  is  the  tube-holder  or  frame,  \\ith  one  tube  removed  so  as  to  show  tlie 
spring,  by  which  the  tube  is  to  be  held  in  place.  To  the  right  is  a  tube  containing  blood  that  has 
been[subjected  to  centrifugal  force,  indicating  ninetj-  per  cent,  of  corpuscular  elements,  as  compared 
with  normal  blood. 

of  the  scale.  A  single  revolution  of  the  large  handle  causes  one 
hundred  and  thirty-four  revolutions  of  the  frame.  The  instrument 
must  be  firmly  secured  to  a  solid  table.  The  method  of  employing  the 
haematokrite  is  simple.  To  fill  the  glass  tube,  a  rubber  tube  is  slipped 
over  the  end  of  the  capillary  pipette,  and  to  the  extremity  of  this  rubber 
tube  a  mouth-piece  is  attached,  precisely  in  the  same  manner  as  when 
the  ha^mocytometer  is  used.  The  glass  tube  or  pipette  must  be  abso- 
lutely clean  and  dry.     The  finger  of  the  patient  is  punctured ;   the 


DISEASES  OF  THE  BLOOD.  729 

blunt  point  of  the  pipette  is  to  be  placed  into  the  blood,  and  the  tube 
completely  filled  by  suction.  The  finger  of  the  operator  is  then  quickly 
applied  to  the  blunt  extremity  of  the  tube,  which  is  next  inserted  into 
the  frame,  and  rotated  at  the  rate  of  ten  thousand  times  per  minute. 
All  that  remains  is  to  read  the  percentage  volume  of  blood  from  the 
scale.  The  divisions  on  the  pipette  are  one-half  millimetre  apart,  so 
that  the  scale  can  be  read  without  difficulty. 

The  entire  procedure  need  not  occupy  more  than  three  minutes. 
In  health  the  volume  of  red  corpuscles  is  a  little  over  fifty  per  cent., 
so  that  by  doubling  the  number  as  read  from  the  scale  we  can  get  a 
proportionate  expression  of  the  percentage  of  corpuscles  in  a  specimen 
as  compared  with  the  normal.  With  the  hsematokrite  of  Daland,  when 
a  column  of  red  corpuscles  obtained  from  a  healthy  man  is  examined, 
the  white  cells  present  a  sharp,  clearly  defined,  and  shallow  white 
band.  When  the  leucocytes  are  much  diminished  in  number,  this 
white  band  is  imperfect,  and  in  places  the  red  color  of  the  biconcave 
disks  is  visible.  In  the  Arnold-Hedin  heematokrite,  diluted  blood  is 
used,  and  the  readings  are  made  more  accurate  by  the  use  of  a  low- 
power  microscope ;  the  motor  runs  by  electricity.  Cabot  objects  to 
the  heematokrite  on  account  of  the  noise  it  makes. 

Exact  results  cannot  be  obtained  by  any  method,  and,  as  shown 
by  Henry,  there  is  a  diurnal  variation  in  the  number  of  the  corpus- 
cles in  health.  Normal  blood  contains  about  five  million  red  blood- 
corpuscles,  nearly  ten  thousand  white  blood-corpuscles,  and  two  hun- 
dred and  fifty  thousand  blood-plaques  or  haematoblasts,^  to  the  cubic 
millimeter,  and  each  red  corpuscle  holds  in  suspension  a  certain  per- 
centage of  hsemoglobin.  Any  marked  variation  in  the  number  of 
corpuscles,  or  the  relation  of  red  to  white,  or  in  the  amount  of 
haemoglobin,  is  indicative  of  an  abnormal  state.  For  accuracy  it  is 
always  requisite  to  study  the  relationship  between  the  different 
elements  of  the  blood. 

In  estimating  the  number  of  red  blood-corpuscles  age  and  sex 
must  be  taken  into  account.  In  healthy  women  the  number  per 
cubic  millimetre  is  somewhat  less  than  in  healthy  men,  being  about 
four  million  five  hundred  thousand ;  in  new-born  infants  it  often  ex- 
ceeds six  million,  as  both  Hayem^  and  Henry  ^  have  found  by  repeated 
observations.  But  in  the  infant  the  constitution  of  the  blood  is  re- 
markable for  its  variability.     The  very  suggestive  observations  of  John 

1  Hayeni,  Du  Sang',  Paris,  1889. 

'■'  Du  Sang  et  de  ses  Alterations  anatomiques,  Paris,  1889. 

■' Amer.  Journ.  Med.  Sci.,  April,  1890. 


730 


MEDICAL  DIAGNOSIS. 


K.  Mitchell  ^  have  shown  that  in  adults  massage  increases  enormously 
for  the  time  being  the  number  of  red  corpuscles  in  the  blood  count. 
Prolonged  fatigue  diminishes  them,  so  does  pregnancy. 

The  white  blood-corpuscles  in  normal  healthy  blood  are  in  the 
proportion  of  about  one  to  six  hundred  of  the  red,  this  varying  some- 
what in  different  individuals  Avithout  being  indicative  of  disease. 
AVhen  the  red  blood-corpuscles  are  reduced  in  number,  the  propor- 
tion of  leucocytes  is  greater,  without  there  being  necessarily  an  in- 
crease in  the  number.  The  safest  method  of  procedure  is  to  estimate 
the  number  of  white  corpuscles  to  the  cubic  miUimetre,  so  that  any 
increase  or  diminution  in  their  amount  will  give  their  true  condition 
irrespective  of  the  change  in  the  number  of  red  disks. 


Fig.  71. 


The  hEemoglobiuometer  of  Gowers.    A,  bottle  with  pipette-stopper ;  B,  capillary  pipette ;  C,  graduated 
tube;  D,  tube  containing  standard  tint,  fixed  in  E,  a  wooden  block ;  F,  guarded  needle. 

The  chief  apparatuses  for  estimating  the  hcemoglobin  are  the  h^mo- 
globinometer  of  Gowers,  Fleischl's  haemometer,  Henocque's  h^mato- 
scope,  and  Ohver's  haemoglobinometer.  Of  these,  the  haemometer  of 
Fleischl  is  the  most  used.  Henocque's  is  especially  valuable  for 
spectroscopic  examination.  In  Oliver's  heemoglobinometer  the  blood 
tint  Is  compared  with  definite  tints  of  glass.  Gowers's  apparatus  con- 
sists of  two  glass  tubes  of  exactly  the  same  size.  One  contains  a 
standard  of  the  tint,  of  the  dilution  of  twenty  cubic  millimetres  of 
blood  with  one  thousand  nine  hundred  and  eighty  cubic  millimetres 
of  water.     The  second  tube  is  graduated  to  one  hundred  degrees, 


1  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1893. 


DISEASES  OF  THE  BLOOD.  731 

which  equal  two  cubic  centimetres.  The  twenty  cubic  milUmetres  of 
blood  are  measured  by  a  capillary  pipette.  This  quantity  of  the  blood 
to  be  tested  is  dropped  to  the  bottom  of  the  graduated  tube,  a  few 
drops  of  distilled  water  being  first  placed  in  the  latter,  and  the  mix- 
ture is  rapidly  agitated,  to  prevent  the  coagulation  of  the  blood.  The 
distilled  water  is  then  added  drop  by  drop  until  the  tint  of  the  solu- 
tion is  the  same  as  that  of  the  standard,  and  the  amount  of  the  water 
added  indicates  the  amount  of  haemoglobin. 

Fleischrs  hsemometer  consists  of  a  stand  to  which  is  attached  a 
reflector  made  of  card-board.  On  the  under  surface  of  the  plate 
there  are  two  grooves,  into  which  slides  the  frame,  holding  in  position 
a  wedge-shaped  glass  colored  red,  the  intensity  of  the  hue  being  grad- 
uated from  zero  to  one  hundred  and  twenty  degrees.  The  frame  is 
moved  by  means  of  a  thumb-screw  so  that  when  it  is  operated  the 
tinted  glass  passes  beneath  one  of  the  compartments  of  the  compar- 
ing vessel.  The  horizontal  projection  of  the  partition  of  this  vessel 
should  fall  directly  upon  the  outer  edge  of  the  glass  wedge  when  the 
instrument  is  properly  adjusted.  In  operating  the  instrument,  care 
should  be  taken  to  have  everything  perfectly  clean.  Accompanying 
each  apparatus  are  a  glass  pipette  for  dropping  the  water  into  the 
compartments,  and  several  minute  capihary  tubes  for  securing  the 
Wood. 

The  compartments — that  is,  the  blood  and  wedge  compartments 
— are  filled  almost  to  the  top  with  distilled  water,  and  the  vessel  is 
placed  in  situ.  The  instrument  should  then  be  so  arranged  and  the 
reflector  so  adjusted  as  to  secure  the  full  rays  of  light  from  either  a 
candle,  a  lamp,  or  a  gas-flame.  Before  securing  the  blood,  the  tip  of 
the  middle  finger  of  the  left  hand  should  be  carefully  cleansed  and 
dried.  The  automatic  blood-pipette,  with  a  capacity  of  six  and  a  half 
cubic  millimetres,  and  about  eight  millimetres  long,  to  which  is  at- 
tached a  frail  wire  for  its  manipulation,  should  always  be  greased,  to 
prevent  the  blood  from  adhering  to  its  sides.  This  is  dipped  into  the 
blood  sideways,  to  facilitate  the  flow  into  the  tube  :  the  greatest  accu- 
racy is  essential  to  the  correctness  of  the  test.  With  as  little  delay  as 
possible  the  tube  is  then  placed  into  the  blood  compartment  and  its 
contents  allowed  to  escape,  aiding  by  gently  movmg  the  tube  back  and 
forth  along  its  own  axis.  The  diluted  blood  remaining  in  the  tube  is 
then  washed  out  by  means  of  the  pipette  and  allowed  to  flow  into  the 
compartment.  This  is  filled,  as  is  the  wedge  compartment,  with 
distilled  water,  care  being  taken  not  to  allow  the  fluid  in  the  two 
chambers  to  run  together,  and  that  the  upper  surface  of  the  water  is 
perfectly  level,  neither  curved  nor  concave. 


732  MEDICAL  DIAGNOSIS. 

The  blood  is  now  ready  for  examination.  In  looking  at  the  com- 
partment the  eyes  should  be  shaded,  that  the  direct  rays  of  light  may 
not  cause  error  in  the  observation.  The  thumb-screw  is  turned, 
which  slowly  moves  the  wedge  from  right  to  left ;  this  movement  is 
continued  until  the  eye  can  perceive  no  difference  in  color  between 
the  two  compartments :  should  the  difference  be  imperceptible  for  a 
considerable  distance,  then  the  point  at  which  the  color  appears 
lighter  and  that  at  which  it  appears  darker  should  both  be  noted  and 
the  mean  ascertained.  The  number  of  degrees — that  is,  the  percent- 
age of  hgemoglobin  as  compared  with  healthy  blood,  which  is  taken 
as  one  hundred — will  be  found  on  the  movable  slide. 

Another  and  easier  method  of  estimating  the  haemoglobin  is  by 
taking  the  specific  gravity  of  the  blood.  This  is  most  readily  done  by 
Hammers chlag's  method.  It  consists  in  mixing  in  an  ordinary  uri-. 
nometer  glass  such  quantities  of  chloroform  and  benzol  as  to  mark 
1059,  the  specific  gravity  of  normal  blood.  A  drop  of  blood  in  a 
pipette  is  blown  into  this  chloroform-benzol  mixture,  and  does  not 
mix,  but  is  seen  to  float.  If  it  sink,  add  chloroform,  a  few  drops  at  a 
time ;  if  it  rise  to  the  top,  add  benzol  until  the  drop  of  blood  remains 
stationary  in  the  body  of  the  liquid,  indicating  that  it  has  the  same 
specific  gravity  as  that  of  the  whole  mixed  fluid.  The  specific  gravity 
is  then  taken  with  the  urinometer. 

From  the  specific  gravity  of  the  blood  we  can  deduce  the  percent- 
age of  hasmoglobin.     Here  is  Hammerschlag's  table  : 

Specific  Gravity.  Haemoglobin.  Specific  Gravity.  Hsemoglobin. 

1033-1035  =  25-30  per  cent.  1048-1060  =  65-65  per  cent. 

1035-1038  =  30-35        "  1050-1053  =  65-70 

1038-1040  =  35-40        "  1053-1055  =  70-75 

1040-1045  =  40-45        "  1056-1057  =  75-85 

1045-1048  =  45-55        "  1057-1060  =  85-95 

In  computing  the  hsemoglobin  from  the  specific  gravity  of  the 
blood,  we  must  bear  in  mind  that  it  varies  considerably  in  dropsies, 
and  that  the  weight  of  the  leucocytes  causes  it  always  to  be  relatively 
higher  in  leuksemia. 

A  hsemoglobinometer  based  on  the  principle  of  the  comparison  of 
a  thin  film  of  undiluted  blood,  illuminated  by  candle-light,  with  a 
graduated  color  scale,  has-  been  invented  by  Arthur  Dare,^  and  fur- 
nishes a  rapid  method  of  hsemoglobin  estimation. 

'  More  important  even  than  estimating  the  number  of  the  corpuscles 

^  Philadelphia  Medical  Journal,  April,  1900. 


DISEASES  OF  THE  BLOOD.  733 

or  the  amount  of  haemoglobin  is  the  microscopical  study  of  the  blood, 
both  in  a  fresh  and  dried  state,  and  especially  with  the  aid  of  stains. 
A  drop  of  blood,  taken  from  the  tip  of  the  finger  or  the  lobe  of  the 
ear,  is  allowed  to  fall  on  a  slide,  and  a  cover-glass  is  placed  over  it. 
This  answers  for  the  study  of  the  ordinary  character  of  the  red  cor- 
puscles, of  the  leucocytes,  and  of  malarial  parasites.  But  for  finer 
study  preserving  fluids  must  be  used,  which  are  neutral  diluting  fluids, 
unstained  or  stained.  Of  the  neutral  unstained  solutions  those  of 
Gowers,  or  Hayem,  are  mostly  used.  Gowers's  solution  consists  of 
sodium  sulphate,  104  grains  ;  acetic  acid,  1  drachm  ;  distilled  water, 
4  ounces  ;  Hayem's  solution,  of  perchloride  of  mercury,  0.5  gramme  ; 
sulphate  of  sodium,  5  grammes  ;  chloride  of  sodium,  ]  gramme ;  dis- 
tilled water,  200  grammes.  Another  diluting  solution  much  employed 
for  clinical  purposes  is  that  of  Toisson,  which,  as  it  is  colored,  is 
especially  valuable  in  enabling  us  to  distinguish  the  leucocytes,  which 
it  colors  blue,  from  the  red  blood-corpuscles,  and  to  determine  their 
relative  proportion.  It  consists  of  glycerin  (neutral),  30  cm. ;  sodium 
sulphate,  8  grammes  ;  sodium  chloride,  1  gramme ;  methyl-violet, 
0.025  gramme  ;  distilled  water,  160  cm. 

To  obtain  permanent  preparations,  and  for  purposes  of  greatest 
accuracy,  the  examination  of  the  blood  in  films,  especially  in  stained 
blood  films,  is  necessary, — a  method  which  we  chiefly  owe  to  Ehrlich. 
Blood  films  are  usually  prepared  by  allowing  a  drop  of  blood  to  fall 
on  a  perfectly  clean  cover-glass,  to  cover  it  with  another,  and  then 
gently  slide  one  over  the  other.  The  film  dries  in  a  few  seconds,  or 
rapid  drying  can  be  insured  by  swaying  it  in  the  air,  or  heating  it  over 
an  alcohol  lamp  or  for  ten  minutes  in  a  dry  heat  sterilizer  at  a  tem- 
perature from  100°  to  150°.  Immersion  for  about  half  an  hour  in 
equal  parts  of  ether  and  absolute  alcohol,  as  advised  by  Nikiforoff,  is 
an  excellent  method  for  fixing  a  blood-film. 

But  staining  may  be  essential,  and  this  is  done  chiefly  by  aniline 
dyes.  These  are  classified  by  Ehrlich  as  acid,  basic,  and  neutral ;  and 
especially  in  studying  leucocytes  we  make  the  greatest  use  of  this 
division.  The  chief  acid  stain  is  eosin ;  methyl-green  or  methylene- 
blue  represents  the  basic  stains  ;  neutral  stains  are  a  mixture  of  both  ; 
for  instance,  acid  fuchsin  with  methylene-blue  or  green. 

One  of  the  most  generally  used  stains  is  Ehrlich's  triple  stain  ;  it 
consists  of  a  saturated  watery  solution  of  orange  G,  24-27  cc. ;  acid 
fuchsin,  16-33  cc. ;  methyl-green,  25  cc. ;  then  add  water,  60  cc. ;  ab- 
solute alcohol,  40  cc. ;  glycerin,  20  cc.  The  mixture  should  stand  for 
one  or  two  weeks  before  being  used.  Preparations  ought  to  be  ex- 
posed to  the  stain  for  several  hours,  having  been  previously  thoroughly 

4r. 


734  MEDICAL   DIAGNOSIvS. 

heated ;  and  to  be  preserved  should  be  washed,  dried,  and  mounted 
in  Canada  balsam.  The  modification  of  the  Ehrlich  stain,  known  as 
the  Ehrhch-Biondi  stain,  is  also  much  employed. 

Stains  are  used  as  a  means  of  classifying  the  leucocytes.  Those 
containing  granules  that  stain  deeply  with  eosin  or  other  acid  aniline 
stains,  and  show  as  coarse,  prominent  granules,  are  called  eosinophiles. 
Cells  with  fine  granules  which  stain  with  basic  aniline  dyes,  as  with 
methylene-blue,  are  basophiles.  Granules  which  stain  with  a  mixture 
of  basic  and  acid  stain,  as  acid  fuchsin  and  methylene-blue,  are  neu- 
trophile^.  They  are  also  very  conveniently  stained  by  Ehrlich's,  or 
Ehrlich-Biondi's,  triple  stain,  and  the  granules  are  then  violet  or  lilac, 
unlike  the  red  or  brownish-red  coarse  granules  of  the  eosinophiles. 
By  Ehrlich's  stains  the  nuclei  of  the  leucocytes  are  stained  greenish 
blue. 

In  the  minute  study  of  the  blood  we  pay  close  attention  to  its 
three  elements,  the  red  corpuscles,  or  erythrocytes ;  the  white  cor- 
puscles, or  leucocytes  ;  and  the  blood-plaques,  or  blood-plates. 

Red  Corpuscles. — The  red  corpuscles  are  of  various  sizes.  They 
have,  according  to  Hayem,  a  mean  diameter  of  7.5  micromillimetres, 
the  micromillimetre  being  yoV-oth  part  of  a  millimetre ;  their  color  is 
due  to  heemoglobin.  Prolonged  fatigue  and  menstruation  diminish 
them.  Their  size  varies  much  in  disease.  We  may  find  many  dwarf 
corpuscles  or  mycrocytes^  having  a  diameter  of  from  three  to  six  micro- 
millimetres,  or  numerous  giant-cells,  or  megalocytes,  with  a  diameter 
from  nine  to  fourteen  micromillimetres.  In  the  latter,  the  amount  of 
haemoglobin  is  increased,  and,  in  consequence,  where  they  abound,  as 
in  severe  anaemias,  there  is  a  high-color  index. 

The  red  corpuscles  in  disease  not  only  undergo  changes  in  size  but 
in  form.  They  lose  their  disk  shape,  and  show  irregular  thickenings 
and  projections  at  their  borders,  forming  the  so-called  poikilocytes, 
common  in,  but  not  characteristic  of,  pernicious  anaemia,  and  to  be 
regarded  essentially  as  a  sign  of  degeneration.  So,  too,  according  to 
Ehrlich,  is  it  a  sign  of  degeneration  or  of  death  of  the  corpuscle,  when 
with  stains  of  eosin  and  haematoxylin  the  red  corpuscles  become  violet 
or  purple  instead  of  pink  or  red.  Where  the  corpuscles  are  found  to 
be  very  pale  or  colorless,  it  is  a  proof  of  a  low  state.  These  "  shadow 
corpuscles"  are  especially  seen  in  protracted  typhoid  fever  and  where 
the  blood  is  undergoing  destruction  and  its  heemoglobin  has  been  lib- 
erated from  the  red  blood-cells. 

A  very  striking  change  in  the  red  corpuscles  is  their  nucleation. 
This  is  never  normal  in  the  adult  except  in  the  immature  red  cor- 
puscles in  the  bone-marrow,  and  is  best  seen  in  dry  films  stained  with 


DESCRIPTION   OF   PLATE   V. 

RED    CORPUSCLES    AND    LEUCOCYTES. 

The  specimens  were  prepared  by  Dr.  Boston,  Bacteriologist  to  the  Clinical 
Laboratory  of  the  Pennsylvania  Hospital,  from  cases  chiefly  of  ansemia,  pernicious 
anaemia,  and  leuksemia  ;  they  were  drawn  by  Mr.  Louis  Schmidt  from  Queen  Micro- 
scope, Obj.  -^^  oil  immersion,  eye  piece  2,  tube  length  160  mm.,  and  exhibit  the 
effects  of  different  stains. 

The  Red  Blood- Corpuscles. — The  preparations  are  stained  with  eosin  and 
hgematoxylin. 

The  first  group  represents  normal  blood-cells  and  shows  a  slight  variation  in 
their  size  ;  next  comes  a  group  of  microcytes,  of  which  two  are  deeply  stained,  the 
so-called  Eichhorst  corpuscles.  Following,  in  the  same  line,  are  a  number  of  large 
red  corpuscles,  or  megalocytes,  the  two  on  the  right  showing  some  degree  of  vacuo- 
lation. 

The  second  line  begins  with  a  group  of  poikilocytes,  of  various  size,  shape, 
and  color ;  next  is  a  group  of  pale  or  shadow  corpuscles,  followed  by  nucleated 
corpuscles  of  about  the  normal  size, — normoblasts.  The  number  of  nuclei  varies  ; 
in  some  the  nucleus  is  partially  extruded.  The  smallest  elements  shown  are  mi- 
croblasts.  Next  will  be  found  a  number  of  megaloblasts,  or  large  nucleated  red 
corpuscles. 

Leucocytes. — -The  first  group  shows  three  small  lymphocytes,  the  second  two 
large  lymphocytes,  all  stained  with  Ehrlich's  tri-stain.  Following  is  a  group  of 
four  polymorphonuclear  neutrophiles.  The  first  two  are  stained  with  Ehrlich's 
tri-stain  ;  the  other  two  with  Ehrlich-Biondi  stain,  exhibiting  fine  neutrophilic 
granules. 

In  the  next  line  are  shown  normal  eosinophilic  cells,  of  two  or  more  nuclei. 
The  protoplasm  contains  large  granules  deeply  stained  with  eosin.  Next  are  two 
mast  cells,  stained  with  Ehrlich's  stain.  A  group  of  myelocytes,  stained  with 
Ehrlich's  stain,  completes  this  line.  Immediately  below,  on  the  last  line,  is  shown 
a  group  of  the  same  cells  stained  with  Ehrlich-Biondi  stain,  as  is  also  the  group 
in  the  lower  left-hand  corner,  showing  marrow-cells  containing  eosinophile  gran- 
ules, or  eosinophile  myelocytes. 


Plate  Y 
r&d  blood-corpuscles. 


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i 


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LEUCOCYTE-S. 


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DISEASES  OF  THE  BLOOD.  735 

eosin-hcTematoxylin,  or  methylene-blue ;  the  stain  of  the  nucleus  is 
especially  deep.  The  nucleated  blood-corpuscles  are  termed,  accord- 
ing to  their  size,  normoblasts,  microblasts,  and  megaloblasts.  The 
normoblasts  are  of  the  same  size  as  the  ordinary  red  corpuscle,  and 
usually  have  a  single  nucleus  which  stains  deeply ;  their  outline  is 
often  irregular.  They  are  a  sign  of  new  formation  of  blood,  of  an 
attempt  at  regeneration  of  the  blood  from  the  marrow,  and  may 
occur  in  crops,  the  "  blood  crisis"  of  Van  Noorden.  The  normo- 
blasts are  found  in  marked  ansemics. 

The  microblasts  are  nucleated  red  corpuscles,  of  smaller  size  than 
the  normal  corpuscles.  Their  occurrence  is  comparatively  infrequent. 
The  megaloblasts  are  much  larger  than  the  normoblasts,  being  from 
ten  to  twenty  micromillimetres  in  diameter.  The  nucleus  is  very 
large,  and  takes  a  pale  stain ;  the  protoplasm  around  it  stains  deeply 
with  eosin.  Megaloblasts  are  never  found  in  healthy  blood ;  they 
indicate  an  abnormal  state  of  the  bone-marrow.  They  are  a  sign  of 
degeneration,  and  are  of  grave  import  when  in  large  numbers.  Both 
normoblasts  and  megaloblasts  may  become  poikiloblasts. 

The  red  corpuscles  stain  especially  with  eosin ;  cells  that  stain 
with  several  colors  from  the  same  mixture,  as  with  the  Ehrlich- 
Biondi  stain,  becoming  purple  or  gray  or  brownish  in  spots,  are 
called  j^olychromatophiles.  They  are  especially  met  with  in  perni- 
cious anaemia. 

When  blood  has  been  standing  for  a  short  time  the  corpuscles 
form  in  rouleaux,  and  a  fine  net-work  of  fibrin  is  also  seen.  Rouleaux 
and  the  net-work  of  fibrin  both  show  generally  more  markedly  and 
quickly  in  inflammatory  conditions.  Decided  net-works  are  also  met 
with  in  many  infectious  diseases.  Absence  of  rouleaux-formation 
never  exists  in  health. 

Leucocytes. — The  white  blood-corpuscles,  or  leucocytes,  are  pale, 
homogeneous  or  slightly  granular,  spherical  cells,  devoid  of  haemo- 
globin. They  are  larger  than  the  red  corpuscles,  but  in  number  are 
few  compared  with  these ;  ten  thousand  to  the  cubic  millimetre  is  the 
normal  limit.  They  increase  after  a  meal  and  during  pregnancy,  and 
are  numerous  in  the  newly-born  and  in  infancy.  They  contain  one 
or  several  nuclei,  are  mostly  ameeboid,  and  some  of  them  possess  the 
power  of  attacking  and  digesting  bacteria,  therefore  are  "  phagocytic." 
The  leucocytes  are  variously  affected  by  aniline  dyes,  as  has  been 
already  explained,  but  are  stained  violet  or  lilac.  Among  the  stained 
leucocytes  the  eosinophlle  cells  are  very  important.  These  are  ac- 
tively amoeboid.  They  are  increased  in  asthma,  in  litliEemia,  in 
affections  of  the  liver,  in  trichiniasis,  and  often  in  spleno-medullary 


736  MEDICAL   DIAGNOSIS. 

leuksemia ;  they  are  diminished  in  influenza,  in  malignant  tumors,  in 
sepsis. 

The  chief  forms  of  leucocytes  in  normal  blood  are  the  small 
uninucleated  leucocytes,  the  large  uninucleated  leucocytes,  and  the 
multinucleated  leucocytes.  The  first  of  these,  also  called  the  small 
lymphocytes^  are  estimated  by  Stengel  at  twenty-five  per  cent. ;  the 
large  uninucleated  or  hyaline  cells  at  three  to  six  per  cent. ;  the  mul- 
tinucleated neutrophile  cells  at  sixty-five  to  seventy-five  per  cent. ;  the 
eosinophile  cells  not  above  three  per  cent.  Cabot  gives  similar  pro- 
portions, but  adds  "  mast  cells."  These  are  his  figures  :  small  lym- 
phocytes, twenty  to  thirty  per  cent. ;  large  lymphocytes  (same  in 
structure,  only  larger),  four  to  eight  per  cent. ;  polymorphonuclear 
neutrophiles,  sixty-two  to  seventy  per  cent, ;  eosinophiles,  one-half  to 
four  per  cent. ;  "  mast  cells,"  one-fortieth  to  one-half  per  cent.  Some 
observers  describe  separately,  as  a  transitional  or  intermediate  form, 
the  large  uninucleated  leucocytes  in  which  the  nucleus  is  indented 
or  horseshoe-shaped. 

The  small  lymphocytes  are  about  the  same  size  as  the  red  corpus- 
cles ;  there  is  extremely  little  protoplasm,  and  they  are  not  amoeboid 
or  phagocytic ;  the  large  multinucleated  leucocytes  are  considerably 
larger ;  they  are  both  actively  amoeboid,  phagocytic,  and  neutrophilic, 
and  the  granules  do  not  stain  thoroughly  except  with  triple  stains 
like  Ehrlich's,  The  so-called  "  mast  cells"  occur  in  health  in  only 
very  small  numbers.  They  are  large,  having  a  diameter  of  twenty 
micromillimetres  or  upward,  and  are  coarsely  granular.  They  stain 
with  basic  dyes,  with  dahlia  or  methylene-blue,  are  therefore  baso- 
philic, but  do  not  show  themselves  with  Ehrlich's  triple  stain.  They 
get  into  the  blood  chiefly  from  the  connective  tissue.  There  has 
been  some  doubt  as  to  whether  they  are  not  pathological ;  there  is 
none  as  regards  the  myelocytes^  or  marrow-cells.  They  are  very  large 
cells  with  a  pale  nucleus,  which  with  Ehrlich's  stain  is  seen  as  a 
pale-stained  nucleus  nearly  filling  the  cell ;  the  protoplasm  contains 
fine  granules.  The  myelocytes  are  found  in  various  intoxications,  in 
myxoedema,  in  syphilis,  but  in  large  numbers  only  in  medullary  or 
spleno-medullary  leukaemia, 

Blood-Plates. — These,  discovered  by  Hayem,  and  called  by  him 
hgematoblasts,  are  small  round  or  oval  bodies  of  faintly  yellow  color, 
and  very  adherent.  They  may  be  seen  in  fresh  blood,  when  imme- 
diately examined.  They  are  smaller  than  the  red  corpuscles,  color- 
less, and  very  cohesive.  They  are  best  studied  with  Hayem's  solution, 
or  a  one  per  cent,  solution  of  osmic  acid ;  they  stain  faintly  with 
aniline  dyes,  and  number  about  two  hundred  thousand  to  the  cubic 


DISEASES  OF  THE  BLOOD. 


737 


millimetre.  They  are  observed  to  be  increased  in  anaemias  unac- 
companied by  fever,  and  after  loss  of  blood ;  they  are  diminished  in 
cachexias,  particularly  in  cancer,  protracted  typhoid  and  typhus  fevers, 
in  erysipelas,  and  in  all  infectious  fevers  with  high  temperatures. 

It  is  often  a  matter  of  great  convenience  to  represent  the  blood- 
examinations  graphically.  An  excellent  chart  for  this  purpose  is  in 
use  at  the  Johns  Hopkins  Hospital.  Fig.  72  shows  it,  and  the  manner 
in  which  the  record  is  made. 

Fig.  72. 


120% 
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BLACK  =  RED  CORPUSCLES 


RED  =  HAEMOGLOB1N 


BLUE=COLORLESS  CORPUSCLES 


Chart  showing  blood-changes  in  chlorosis. 


Ansemia. — Poverty  of  blood  is  met  with  as  a  consequence  of 
profuse  or  frequently  recurring  hemorrhages,  of  insufficient  nourish- 
ment, of  affections  which  prevent  the  nutriment  taken  from  being 
properly  absorbed  or  assimilated,  of  disease  of  the  blood-making 
organs,  and  of  profuse  chronic  discharges,  which  drain  the  blood  of 
many  of  its  important  elements,  and  especially  of  its  albumin.  Be- 
sides  these    causes  of   anaemia,  we  find  it  occasioned  by  particular 


738  MEDICAL  DIAGNOSIS. 

poisons,  as  by  malaria ;  by  syphilis ;  by  uterine  complaints ;  by  the 
absorption  into  or  the  retention  of  noxious  ingredients  in  the  blood ; 
by  rapid  destruction  of  the  red  corpuscles,  as  in  fevers  ;  and  as  consec- 
utive to  malignant  growths,  and  organic  diseases  in  general.  Again,  it 
is  sometimes  encountered  without  our  being  able  to  trace  it  to  any 
obvious  source.  This  is  the  so-called  primary  ansemia,  as  distin- 
guished from  the  instances  in  which  the  anaemia  is  symptomatic  of 
some  disease,  or  secondary.  But  under  all  circumstances,  except  in 
the  anaemia  after  hemorrhage,  where  all  the  constituents  of  the  blood 
are  diminished  together,  we  have  to  deal  with  a  blood  deficient  in  red 
corpuscles,  and  the  corpuscles  are  often  badly  shaped,  and  shrunken 
at  their  edges.  In  extreme  anaemic  conditions,  large  and  giant  corpus- 
cles are  common ;  the  leucocytes  and  blood-plates  are  not  altered,  or 
are  somewhat  diminished.  In  secondary  anaemia  there  is  more  apt  to 
be  an  increase  of  leucocytes,  the  red  corpuscles  are  dwarfed,  and  there 
are  normoblasts  rather  than  megaloblasts.  The  haemoglobin  may  be 
increased  relatively,  or  it  may  be  diminished,  or  it  may  not  be  ma- 
terially changed.  Angemia  begins  witli  four  million  corpuscles  to  the 
cubic  millimetre. 

Whatever  may  have  given  rise  to  the  aneemia,  the  manifestations 
of  the  disorder  when  well  marked  are  much  the  same.  The  patient 
is  weak  and  pale ;  his  lips  and  tongue  have  lost  their  red  color ;  the 
eye  is  pearly  ;  his  pulse  is  feeble,  and  generally  accelerated  ;  the  appe- 
tite is  deficient  or  depraved ;  the  bowels  are  apt  to  be  costive.  Yet 
persons,  who  are  apparently  well  nourished  and  are  not  pale,  may 
have  deficiency  of  red  blood-cells  and  of  haemoglobin.  Exercise 
induces  great  fatigue,  shortness  of  breath,  and  palpitation ;  and  the 
disturbance  of  the  heart  may  be  associated  with  cardiac  murmurs  or 
with  blowing  sounds  in  the  cervical  veins,  and  is  at  times  so  per- 
sistent as  to  lead  to  structural  changes.  In  some  cases,  we  meet 
among  the  symptoms  with  obstinate  headache  and  with  dropsy,  and 
in  many  with  a  persistent  pain  in  the  left  side,  in  the  region  of  the 
spleen. 

Anaemia  may  be  owing  to  the  presence  of  parasites,  such  as  intes- 
tinal worms.  The  very  marked  form  which  is  common  in  Egypt  is 
that  due  to  anchylostomiasis.  The  anchylostomum  duodenale  is  taken 
into  the  body  in  the  muddy  water,  or  by  eating  earth  containing  the 
embryos  of  this  worm.  Anchylostomiasis  is  an  insidious,  wasting 
disease,  characterized  by  progressive  anaemia  and  by  digestive  and 
nervous  deterioration,  occurring  chiefly  in  earth  and  brick  laborers  of 
warm  climates,  caused  by  the  presence  in  the  duodedum  and  jejunum 
of  a  blood-sucking,  rhabditic,  nematode  worm.     The  blood   shows 


DISEASES  OF  THE  BLOOD.  739 

great  diminution  of  red  blood-corpuscles,  reduction  of  haemoglobin,* 
megaloblasts,  indeed  all  the  signs  characteristic  of  pernicious  anaemia ; 
but,  as  in  bothriocephalus  latus,  these  disappear  with  the  expulsion 
of  the  parasite. 

Chlorosis. — Here  the  pallid,  wax-like  countenance,  the  very  pale 
lips,  and  the  pearly  eye  afford  unmistakable  evidence  of  the  deteriora- 
tion of  the  blood,  consisting  chiefly  in  great  deficiency  of  haemoglobin, 
which  is  usually  much  more  marked  than  the  reduction  in  the  red 
corpuscles ;  these,  indeed,  may  be  of  almost  normal  amount.  The 
corpuscles  are  pale.  The  smaller  corpuscles,  the  microcytes,  generally 
abound,  and  nucleated  red  cells  are  not  infrequent ;  the  leucocytes 
are  not  affected.  Lloyd  Jones  ^  regards  the  disease  as  an  exaggeration 
of  a  change  which  occurs  in  the  blood  of  the  healthy  female  at 
puberty,  and  which  leads  to  an  increase  of  the  amount  of  blood- 
plasma  associated  with  a  diminution  of  the  amount  of  haemoglobin. 
Meinert  has  noted,  in  cases  of  chlorosis,  gastroptosis  combined  with 
enteroptosis  and  occasionally  movable  kidney,  and,  as  these  displace- 
ments are  produced  by  wearing  corsets,  his  deduction  is  that  chlorosis 
is  due  to  faulty  wearing-apparel.  Chlorosis  may  also  attend  the  absorp- 
tion of  ptomaines  from  the  intestines  in  habitual  constipation.  Con- 
siderable stress  has  been  faid  on  the  fact  that  in  chlorosis  there  is  a 
greater  tendency  to  inflammation  of  the  optic  nerve  and  retina  than 
in  pernicious  anaemia,  while  the  tendency  to  retinal  hemorrhage  is 
considerably  less,^ 

The  complaint  is  especially  encountered  in  young  women,  and  is, 
as  a  rule,  associated  with  amenorrhoea.  Indeed,  many  restrict  the 
term  to  the  obvious  anaemia  combined  with  suppression  of  the  menses, 
so  often  affecting  girls  about  the  age  of  puberty.  In  pure  chlorosis, 
organic  diseases  of  the  gastro-intestinal  apparatus  of  the  spleen  and 
lymphatic  glands,  or  of  the  lungs  and  kidneys,  are  absent ;  the  tem- 
perature shows  a  slight  rise ;  the  nutrition  of  the  body  is  fairly  well 
kept  up ;  the  urine  is  pale  and  abundant,  containing  but  a  small 
amount  of  phosphates.  Forchheimer  finds  a  diminution  of  urobilin 
in  the  urine,  which  he  regards  as  of  considerable  diagnostic  impor- 
tance. The  nervous  system  is  irritable.  Pigmentation  about  the 
second  joints  of  the  fingers,  on  their  dorsal  surface,  has  been  noticed,* 
Sometimes  these  symptoms  of  chlorosis  happen  before  puberty  ;  or 


^  Sandwith,  Proceedings  XI.  International  Med.  Congress,  Rome,  1894. 

2  Brit.  Med.  Journ.,  July,  1894. 

^  Stephen  Mackenzie,  Sajous's  Annual,  1895,  vol.  i.  L.  10. 

*  Bouchard  ;  also  Pouzet. 


740  MEDICAL  DIAGNOSIS.      ' 

there  are  relapses  of  the  malady  in  middle  age.  Boys  about  the  age 
of  puberty  may  also  develop  the  manifestations  of  chlorosis.  Virchow 
has  pointed  out  the  frequent  association  of  chlorosis  with  narrowing 
of  the  aorta  and  of  the  great  arteries,  and  such  cases  are  distmguished 
by  obstinate  relapses.  There  is  a  variety  of  chlorosis  in  connection 
with  tubercle,  at  times  preceding  it.  Chlorosis  as  well  as  ansemia 
may  be  associated  with  nasal  hypertrophies  or  adenoid  vegetations  m 
the  vault  of  the  pharynx/  and  be  relieved  by  their  removal.  Both 
the  corpuscles  and  the  haemoglobin  may  be  decidedly  decreased  in 
consequence  of  surgical  shock.^ 

Fever  may  occur  in  chlorosis,  though  to  but  slight  degree.  Jac- 
coud  attributes  it  to  cmoxcemia,  the  deficiency  of  oxygen  in  the  blood 
acting  as  a  stimulant  to  the  calorific  centres.  Fever  may  be  also  due 
to  local  causes,  such  as  phlegmasia  alba  dolens. 

Pernicious  Anaemia. — This  is  an  extreme  anaemia  advancing 
steadily,  or  with  remissions,  towards  a  fatal  ending ;  yet  no  certain 
cause  can  be  detected  for  the  profound  and  disastrous  alteration  the 
blood  is  undergoing.  To  pernicious  anaemia  belong  most  of  the  cases 
of  "  essential"  or  ''  idiopathic  anaemia." 

The  disorder  is  most  frequent  in  women,  and  has  been  especially 
observed  in  childbearing  women  after  several  pregnancies ;  still,  it 
also  often  happens  in  men,  especially  before  the  age  of  forty.  It 
sometimes  seems  to  have  its  origin  in  long-continued  dyspepsia  or 
diarrhoea,  and  atrophy  of  the  gastric  tubules  ;  or  to  arise  after  pro- 
tracted hemorrhages  or  incessant  worry, — after,  indeed,  slowly  but 
steadily  acting  debilitating  influences  ;  and  it  has  been  noted  to  arise 
after  nervous  shock,  or  to  be  of  parasitic  origin,  and  due  to  worms, 
sometimes  to  a  tape-worm, — bothriocephalus  latus.^  But  in  the  ma- 
jority of  instances  it  originates  seemingly  without  cause,  and,  although 
it  has  periods  of  deceptive  improvement  that  may  last  for  months, 
or,  as  I  have  known,  even  for  a  year,  it  progresses  relentlessly  towards 
a  fatal  issue.*  It  is  true  that  some  cases  of  recovery  have  been  re- 
corded ;  but  of  these  it  is  not  quite  certain  that  they  presented  all  the 
characteristic  symptoms. 

There  is  an  insidious  beginning,  except  at  times  when  the  anaemia 

^  F.  Oppenheimer,  Berl.  klin.  Wochenschrift,  Oct.  3,  1892  ;  Sajous's  Annual  of 
the  Universal  Med.  Sciences,  vol.  iv.,  1894. 

^Joseph  Leidy,  Jr.,  Transactions  of  the  College  of  Physicians,  Phila.,  1893, 
vol.  XV.  p.  242. 

3  Schmidt's  Jahrb.,  i.,  1891  ;  also  ibid.,  No.  10,  1887  ;  and  Berl.  klin.  Woch- 
ensch..  No.  40,  1886  ;  also  Deutsches  Arch,  fur  klin.  Med.,  Bd.  xxxix. 

*  See  also  case  Avith  remissions  in  Schmidt's  Jahrb.,  No.  4,  1882. 


DISEASES  OF  THE  BLOOD.  741 

develops  itself  in  the  pregnant  state.  Pale  tongue,  bloodless  lips, 
pearly  eye,  becoming  paler,  more  bloodless,  more  pearly,  from  week 
to  week ;  breathlessness ;  palpitation  of  the  heart,  especially  on  exer- 
tion ;  weak  digestion ;  constipation,  or  constipation  alternating  with 
diarrhoea ;  loud  systolic  murmurs  in  the  heart,  and  venous  ham  in  the 
jugulars ;  vertigo,  a  marked  lemon-colored  hue  of  the  skin  about  the 
large  joints,  at  times  jaundice  ;  finally  extreme  exhaustion,  sluggish- 
ness of  mind,  fainting-fits,  and  dropsy,  without  persistent  albumin  in 
the  urine,  or  disease  of  the  liver,  or  enlargement  or  valvular  disease 
of  the  heart,  to  account  for  it, — are  the  prominent  symptoms.  In  the 
later  stages,  too,  hemorrhages  from  the  nose  and  from  the  gums  are 
not  uncommon ;  and  hemorrhages  from  the  uterus  or  from  the  kid- 
neys, or  into  the  skin  and  into  the  retina,  may  be  also  noticed ;  the 
latter  especially  are  very  frequent.  Yet,  notwithstanding  all  these  grave 
signs,  the  body  appears  well  nourished ;  there  is  certainly  no  decided 
emaciation,  except  in  instances  in  which  fever  is  more  than  commonly 
marked.  Now,  fever  is  a  significant  feature  of  progressive  pernicious 
anaemia ;  it  has  been  present  in  every  case  that  I  have  met  mth.  It 
is  not  an  early  symptom,  belonging  to  the  full  development  or  to  the 
latter  part  of  the  disease.  It  is  of  very  irregular  type,  and  not  of  high 
intensity,  the  temperature  rarely  exceeding  103°  F.  It  is  apt  to  be 
continued,  or  to  show  occasional  exacerbations,  followed  by  remis- 
sions, the  febrile  state  lasting  for  days,  or  even  for  a  week  or  two  at  a 
time  ;  then  there  are  periods  of  shorter  or  longer  duration  when  it 
wholly  disappears,  to  come  on  again  in  an  outbreak  attended  mth  all 
the  usual  signs  of  a  febrile  paroxysm  for  which  no  cause  is  apparent. 
Towards  the  end  of  the  case  it  is  not  unusual  for  the  anaemic  fever 
to  have  entirely  ceased,  and  for  the  temperature  to  have  fallen  below 
the  normal  standard.     Pernicious  anaemia  may  run  an  acute  course. 

In  this  perilous  malady  the  red  globules  are  strikingly  diminished 
in  number, — to  about  a  million  and  a  half  or  less  ;  the  white  cor- 
puscles are  not  relatively  altered,  or  they  may  remain  normal,  and 
seem  to  be  increased,  because  the  red  globules  are  much  fewer. 
Towards  the  end  there  may  be,  indeed,  a  true  leucocytosis,'  The 
haemoglobin,  while,  in  the  whole  amount,  markedly  lessened,  is  in  the 
individual  corpuscles  generally  increased,^  the  leucocytes  are  normal 
or  diminished,  the  pale  haematoblasts  are  diminished  and  may  quickly 
assume  irregular  shapes.  The  red  corpuscles  are  generally  increased 
in  size.     Eichhorst  regards  as  a  characteristic  change  that  the  blood 

^  Stengel,  Twentieth  Century  of  Medicine. 
■^  Havem,  Du  Sang.  Paris,  1889. 


742 


MEDICAL  DIAGNOSIS. 


contains  also  a  quantity  of  ill-developed,  small,  spherical,  highly 
colored  red  corpuscles.  But  these  are  not  pathognomonic ;  for  they 
have  been  found  by  Cohnheim  in  medullary  leukgemia,  and  by  Green- 
field in  lymphadenoma ;  on  the  other  hand,  they  are  frequently  ab- 
sent. Besides  this  there  are  giant-cells  of  irregular  shape,  on  which 
Hay  em  ^  lays  great  stress,  also  many  very  large  normal-looking  red 
corpuscles,  some  of  which  are,  however,  nucleated  megaloblasts. 
Nucleated  red  corpuscles  were  detected  in  the  blood  of  all  the  patients 
examined  by  Howard :  ^  the  blood  seems  to  revert  to  a  lower  type. 

Fig.  73. 


Blood  in  pernicious  ansemia,  illustrating  the  irregularly  shaped  blood-cells  (Poikilocytosis). 


This  has  been  also  insisted  upon  by  Henry.  Stengel  regards  the 
nucleated  red  blood-corpuscles  as  a  constant  feature.  The  accom- 
panying cut  (Fig.  73),  from  a  well-marked  instance  of  the  disease, 
shows  the  irregular  shape  of  the  corpuscles  and  their  varied  size  and 
appearance  ;  some  are  nucleated. 

Of  the  real  cause  of  the  disease  we  are  in  ignorance.  No  constant 
lesion  of  the  blood-making  glands  has  been  found ;  but  everything 
points  to  excessive  blood-destruction.  The  structure  of  the  spleen 
and  of  the  lymphatic  glands  is  not  altered ;  the  marrow  of  the  bones 


1  Op.  cit. 

^  Montreal  General  Hospital  Reports,  vol.  i.,  1880. 


DISEASES  OF  THE  BLOOD.  743 

may  or  may  not  be/  Hunter^  has  brought  forward  strong  proof  that 
the  characteristic  anatomical  change  is  the  presence  of  an  excess  of 
iron  in  the  Hver,  the  seat  of  disintegration  of  the  corpuscles  being 
chiefly  in  the  portal  circulation.  The  existence  of  some  toxic  sub- 
stance in  the  circulation  is  highly  probable,  and  by  some  this  is 
thought  to  come  from  intestinal  autointoxication.  Diminished  or 
faulty  hcemogenesis  may  also  exist  and  contribute  to  the  ansemia,  as 
insisted  upon  by  Van  Noorden,^ 

There  is  also  a  close  association  with  structural  disease  of  the 
brain  and  cord.  Degeneration  of  the  lateral  pyramidal  and  lateral  cere- 
bellar tracts,  and  especially  of  the  posterior  columns  of  the  spinal  cord, 
has  been  found.  But  the  cjuestion  of  the  relation  of  these  degenerative 
changes  to  pernicious  anaemia  is  unsettled.  They  have  been  studied 
by  Lichtheim,*  by  Van  Noorden,^  by  Bowman,"  and  more  recently  by 
Burr,''  who  found  the  gray  matter  seldom  even  slightly  involved.  He 
favors  the  view  that  both  the  anaemia  and  the  cordal  lesions  are  due 
to  a  common  cause, — a  poison  or  poisons,  as  in  diphtheria  or  ergotism, 
and  Lichtheim's  opinion  is  similar. 

The  diagnosis  of  pernicious  anaemia  is  never  an  easy  one,  for  it  is 
difficult  to  be  quite  certain  that  no  latent  organic  disease  exists  which 
would  account  for  the  progressive  alteration  of  the  blood.  Indeed, 
without  the  microscopical  features  of  the  blood  a  diagnosis  is  impos- 
sible, and  ought  not  to  be  attempted.  While  no  one  element  is  char- 
acteristic of  pernicious  anaemia,  this  state  of  the  blood  warrants  it : 
red  cells  extremely  low,  two  million  or  lower ;  some,  but  not  marked, 
increase  of  the  white  cells  ;  haemoglobin  variable,  relatively  increased  ; 
high  color-index  ;  many  large  and  many  very  irregularly  shaped  red 
corpuscles  (megalocytes  and  poikilocytes) ;  red  corpuscles,  whether 
of  irregular  shape  and  size  or  not,  frequently  nucleated  (poikiloblasts 
and  megaloblasts). 

With  reference  to  diseases  likely  to  be  confounded  wilh  pernicious 
anaemia,  I  have  more  than  once  known  obscure  organic,  disease  of 
the  stomach,  especially  gastric  cancer,  where  the  tumor  could  not  be 
discerned,  or  contracted  kidney,  with  but  little  albumin  in  the  urine,  and 
where  the  anaemia  was  marked,  to  be  regarded  as  a  typical  illustration 


^Pepper,  Amer.   Journ.  Med.  Sci.,   Oct.  1875;  see  also  Cohnheini,   Virthow's 
Archiv,  Bd.  Ixviii.,  and  Waldstein,  Arch.  f.  Path.  Annt.,  Berlin,  1888,  xci. 
-^  Lancet,  London  Practitioner,  Aug.  1888. 
•'  Quoted  in  Sajous's  Annual  for  1895,  vol.  i.  L.  8. 
''  Congress  fur  Innere  Medizin. 

^  Charite  Annalen,  1891.  "  Brain,  1894. 

'  University  Medical  Magazine,  April,  1895. 


744  MEDICAL  DIAGNOSIS. 

of  the  malady,  until  the  autopsy  revealed  the  true  cause  of  the  fatal 
exhaustion.  M^ith  reference  to  the  former  affection  the  error  is  all  the 
more  likely  to  happen  because  symptoms  of  gastric  disorder  are  usual  in 
progressive  anaemia ;  with  reference  to  disease  of  the  kidney  the  mis- 
leading part  is  that  a  trace  of  albumin  is  occasionally  present  in  pro- 
gressive anaemia.  But  it  is  not  persistent,  is  associated  with  marked 
evidence  of  urobilin  and  with  increase  of  uric  acid,  and  a  microscopi- 
cal examination  of  the  urine  wUl  tell  us  the  real  extent  of  kidney 
affection.  The  cachectic  pallor  of  subjects  of  malignant  disease  may  be 
mistaken  for  the  lemon-  or  straw-colored  appearance  of  the  skin  in  per- 
nicious anaemia,  and  the  anaemia  is  often  pronounced,  and  poikilocytes 
and  normoblasts  are  common.  But  megaloblasts  are  few,  and  this, 
Cabot  states,  is  a  valuable  distinguishing  mark  from  pernicious  anaemia. 
Diseases  of  the  heart  may  be  held  to  be  pernicious  anaemia.  A 
fatty  heart,  in  an  elderly  person,  with  or  without  valvular  disease, 
Avith  failure  of  strength,  and  with  the  peculiar  pallid,  sickly  look  occa- 
sioned by  the  malady,  may  mislead.  But  the  long  duration  of  such 
cases,  and  the  absence  of  fever,  are  strong  points  in  the  case.  Indeed, 
the  error  is  apt  to  be  the  other  way, — that,  overlooking  the  symptoms 
of  profound  anaemia  and  general  failure,  we  regard  the  murmurs  and 
the  other  cardiac  symptoms  which  are  associated  with  the  fatty  heart 
of  pernicious  anaemia,  a  very  commonly  coexisting  lesion,  as  pointing 
to  a  disease  of  the  heart  alone.  The  physical  signs  will  not  always 
assist :  the  murmurs  may  be  very  distinct  and  loud. 

A  number  of  trophic  and  vascular  disturbances  have  followed  sur- 
gical extirpation  of  the  thyroid  gland,  and  have  been  also  noticed  after 
atrophy  of  the  gland  has  occurred.  To  this  condition  the  name  of 
cachexia  strnmipriva  has  been  given.  It  is  distinguished  from  anaemia 
by  the  occurrence  of  signs  of  myxoedema,  often  with  cretinism  and 
circulatory  disturbances,  with  local  asphyxia  and  transient  or  inter- 
mittent albuminuria.  In  some  cases  epilepsy  is  developed,  in  others 
pulmonary  phthisis. 

From  the  other  diseases  of  the  blood  pernicious  anaemia  is  dis- 
tinguished by  the  special  features  of  the  blood  already  mentioned, 
particularly  by  the  large  and  irregular  forms  of  the  blood-cells. 
Besides,  it  differs  from  ordinary  ancemia  by  its  relentless  progress  and 
the  little  influence  the  most  nourishing  diet  and  courses  of  iron  have 
on  it.  Moreover,  the  distinctness  of  the  cardiac  murmurs,  the  slight 
emaciation,  and  the  irregular  outbreaks  of  fever  are  significant.  The 
marked  accessions  of  fever,  the  presence  of  dropsy,  though  moderate, 
the  retinal  extravasations,  the  other  hemorrhagic  symptoms,  and 
the  unyielding  blood-change,  separate  pernicious  anaemia  from  chlo- 


DISEASES  OF  THE  BLOOD.  745 

rosis.  The  pernicious  malady  sometimes  seems  to  develop  out  of  a 
long-standing  chlorosis,  and  then  the  grave  symptoms  just  spoken  of 
prove  its  supervention.  Tlie  same  grave  symptoms  happen  also,  at 
least  the  hemorrhages  are  as  frequent,  and  the  fever  and  dropsy  may 
happen,  in  leukcemia  and  in  pseudo-leukcemia .  But  the  great  increase 
in  the  white  corpuscles,  the  tumefaction  of  the  spleen,  or  the  affections 
of  other  blood-making  parts,  distinguish  the  former  malady ;  and 
pseudo-leukaemia,  while  the  blood  microscopically  may  be  that  of  a 
severe  anaemia,  exhibits  the  enlarged  lymphatic  glands,  their  progres- 
sive invasion,  the  lymphoid  tumors,  the  abdominal  pains,  and  the 
steadily  increasing  emaciation  so  characteristic  of  the  disease.  More- 
over, here  the  red  corpuscles,  as  in  ordinary  anaemia,  are  usually 
smaller  and  paler  than  normal,  and  nucleated  blood-corpuscles  are 
rare,  and  not  of  giant  size ;  and  while  the  corpuscles  are  not  markedly 
diminished  in  number,  the  haemoglobin  is  strikingly  lessened. 

Leucocytosis. — Leucocytosis  is  an  increased  number  of  white 
cells  over  the  normal  amount  as  found  per  cubic  centimetre.  All 
the  different  varieties  of  leucocytes  are  increased,  though  in  patho- 
logical states  the  increase  shows  chiefly  in  the  polymorphonuclear 
cells.  The  leucocytes  are  increased  after  meals,  and  decreased  by 
starvation.  Cabot  advises  to  examine  the  blood  shortly  before  a 
meal,  and  preferably  before  breakfast.  The  leucocytes  are  in  large 
numbers  in  the  new-born,  in  pregnancy,  and  after  parturition.  Path- 
ologically, we  observe  a  marked  increase  of  leucocytes  after  hem- 
orrhages, especially  in  the  polymorphonuclear  cells  ;  in  a  number  of 
infectious  diseases,  such  as  in  typhus  fever,  relapsing  fever,  erysipelas, 
diphtheria,  pneumonia,  scarlet  fever,  smallpox,  cerebro-spinal  menin- 
gitis, malignant  endocarditis,  in  trichiniasis,  in  pyaemic  and  septiceemic 
states  ;  and  in  all  inflammatory  conditions,  including  those  of  the  skin. 
We  also  find  leucocytosis  in  malignant  disease  ;  in  gout  and  in  lith- 
aemia ;  in  uraemia  and  other  toxaemias.  Some  of  the  animal  extracts, 
such  as  of  the  spleen  and  bone-marrow,  produce  it,  and  among  drugs 
pilocarpine  and  antipyrine  do  so  decidedly.  On  the  other  hand,  in 
typhoid  fever,  in  influenza,  in  measles,  in  German  measles,  in  malaria, 
and  in  tuberculosis,  there  is  no  leucocytosis.  It  is  chfficult  to  deter- 
mine at  what  actual  number  of  white  cells  leucocytosis  begins.  Both 
Hayem  and  Stengel  regard  it  as  present  when  the  leucocytes  exceed 
10,000  per  cubic  centimetre.  Leucocytosis  ends,  according  to  some 
authors,  at  70,000,  to  others,  at  100,000,  and  we  are  then  dealing  with 
white  blood,  or  leuk;iemia.  Yet  it  is  not  so  much  the  mere  number 
of  leucocytes  as  their  alterations  and  their  changed  proportions  that 
determine  this. 


746  MEDICAL  DIAGNOSIS. 

Now  it  is  always  most  important  to  study  these  alterations,  and 
the  proportion  the  various  forms  of  leucocytes  bear  to  each  other. 
As  already  stated,  the  multinucleated  cells  are  the  ones  that  in 
leucocytosis,  especially  that  of  pathological  states,  are  mainly  in- 
creased ;  but  in  rickets,  in  syphilis,  in  cervical  adenitis,  in  tumors  of 
the  spleen,  in  far-advanced  cachexias,  and  after  taking  a  course  of 
thyroid  extract,^  the  greatest  relative  increase  may  show  itself  in  the 
lymphocytes.  Cabot  tells  us  that  in  obscure  syphilitic  cases  the  diag- 
nosis may  be  made  by  the  coincidence  of  lymphocytosis  with  increase 
of  the  eosinophiles.  Myelocytes  occur  only  in  pathological  conditions, 
such  as  in  leukaemia  and  in  grave  anaemias,  and  markedly  in  those  of 
syphilis  and  cancer. 

In  the  study  of  alterations  of  the  cells,  we  pay  particular  attention 
to  their  shape,  granulation,  and  the  nuclei.  In  addition  to  typical 
cells,  we  And  in  very  marked  instances  of  leucocytosis  cells  that  are 
not  typical,  but  appear  like  transition  cells.  In  malarial  fevers  and 
cachexias,  and  in  melanosis,  the  leucocytes  are  often  pigmented. 

A  decrease  in  the  number  of  leucocytes  is  found  from  starvation, 
in  low  fevers  of  long  duration,  and  in  pernicious  ansemia.  Diminution 
of  the  leucocytes  is  named  leucopenia.  The  diminished  number  of 
leucocytes  may  not  be  real,  but  be  owing  to  incarceration  in  the  finer 
capillaries.  This  state  has  been  called  by  Maurel  false  hypoleukcemia, 
The  arrest  of  the  white  cells  may  be  due  either  to  vasomotor  con- 
striction of  the  small  capillaries  or  to  direct  action  of  poisonous  agents 
upon  the  leucocytes,  giving  them  a  spherical  shape  and  sluggish  amoe- 
boid movement. 

Leukaemia. — This  morbid  state  consists  in  a  decided  increase  of 
the  white  corpuscles  and  a  decrease  of  the  red.  Under  the  micro- 
scope the  white  globules  of  the  blood,  instead  of  bearing  the  normal 
proportion  of  about  1  to  500  of  the  red,  are  found  in  the  proportion 
of  1  to  6,  or  even  1  to  0.5,  and  cases  have  been  met  with  in  which 
near  the  point  of  death  the  white  corpuscles  have  been  five  times 
as  many  as  the  red.  Besides  the  increase  of  white  corpuscles  and 
the  diminution  of  the  red,  peculiar,  colorless,  shining,  elongated  octa- 
hedral crystals  have  been  pointed  out  by  Neumann  and  by  Charcot. 
Haig  has  stated  that  the  proportion  of  uric  acid  in  the  blood  is  in- 
creased in  splenic  leukaemia.  Jaksch  has  shown  that  the  blood  is  rich 
in  peptone,  although  this  substance  is  rarely  met  with'  in  the  urine  in 
leukaemia.     Mathes  found  deutero-albumoses  in  the  blood  and  serum. 

The  abnormal  condition  exists  in  connection  with  hypertrophy  of 


^  Perry,  New  York  Medical  Record,  Aug.  1896. 


DISEASES  OF  THE  BLOOD.  747 

the  spleen,  "  splenic  leukaemia,"  or  of  the  liver ;  with  other  diseases  of 
these  viscera  ;  and  with  various  malignant  or  non-malignant  affections 
of  the  lymphatic  glands,  "  lymphatic  leukaemia  ;"  or  of  the  thyroid  body, 
especially  with  an  increase  of  the  cellular  elements.  But  none  of  the 
blood-glands  is  so  constantly  and  so  markedly  affected  as  the  spleen. 
We  have,  too,  a  "  myelogenous"  or  medullary  form  of  leukaemia.  In 
splenic  leukaemia  there  are  also  very  often  marked  marrow-changes  ; 
hence  this  is  mostly  described  as  splenic  myelogenous  leukaenjiia,  or 
spleno-medullary  leukaemia. 

The  disorder  may  occur  at  all  ages  ;  it  is  more  common  in  men 
than  in  women.  Leukaemia  is  consequent  upon  obstinate  intermit- 
tents  with  decided  enlargement  of  the  spleen,  syphilis,  over-exertion, 
long-continued  mental  depression,  chronic  intestinal  catarrh,  and 
blows  on  the  splenic  region.  The  form  affecting  the  marrow  of  the 
bones  frequently  results  from  injury  to  the  bones.  Ebstein  reported 
cases  of  leukaemia  following  traumatism,  but  the  causative  relationship 
is  not  clearly  made  out.  Yet  in  many  cases  of  leukaemia  no  adequate 
cause  can  be  detected.  Its  beginning  is  usually  gradual  and  ill 
defined ;  sometimes  it  clearly  follows  other  diseases.  When  fully 
developed,  it  occasions,  besides  the  obvious  pallor  and  the  cachectic 
appearance,  feeble  heart  action,  exhaustion,  diarrhoea,  hurried  breath- 
ing, hemorrhages  from  various  parts,  especially  from  the  nose,  profuse 
sweating,  slight  rise  of  temperature  in  the  evening,  increase  of  uric 
acid  in  the  urine,  fleeting  abdominal  pains,  and  dropsy  dependent 
upon  the  enlargement  of  the  spleen  or  of  the  liver,  or  upon  the  leukae- 
mic  new  formations  in  the  latter.  In  some  cases  a  swelling  of  the 
glands  on  both  sides  of  the  throat,  attended  with  inflammation  of  the 
mucous  membrane  of  the  mouth  and  pharynx,  and  followed  by  swell- 
ing of  the  axillary  and  the  inguinal  glands,  precedes  the  enlargement 
of  the  liver  and  of  the  spleen.^  Indeed,  glandular  tumors  are  often 
present ;  the  glands  of  the  groin  are,  as  a  rule,  enlarged.  There  is 
disturbance  of  vision,  connected  with  retinal  changes,  and  in  some  in- 
stances deafness,  and  peritoneal  or  pleural  inflammation,  also  mel- 
ancholy. Pain  in  the  bones,  too,  particularly  in  the  sternum,  is 
observed.  The  medullary  or  myelogenous  variety  is  pre-eminently 
marked  by  pain,  which  is  increased  or  developed  by  pressure  over 
the  sternum  and  ribs  and  over  other  affected  bones.^ 


'  Mosler,  in  Virchow's  Arcliiv,  xliii.  ;  Dunn,  Amer.  Journ.  Med.  Sci.,  March, 
1894,  describes  a  case  with  s^'rowths  in  the  orbits. 

*  Mosler,  Berlin,  klin.  Wochensclirift,  xiii.,  1876;  and  Sclmiidi's  Jahrl).,  No. 
10,  1877. 


748  MEDICAL   DIAGNOSIS. 

The  diagnosis  of  leukssmia  is  possible  only  by  the  microscopical 
examination  of  the  blood,  which  detects  the  decided  increase  of  the 
white  corpuscles,  and  especially  by  studying  the  kinds  of  cells  present 
in  stained  films  of  the  blood.  In  the  most  common  variety,  splenic 
or  spleno-medullary  leukaemia,  for  in  this  combination  it  generally 
exists,  we  may  be  also  able,  even  early,  to  discern  the  enlargement  of 
the  spleen,  and  to  find  the  evidences  of  cachexia  in  the  appearance  of 
the  patient,  and  in  recurring  epistaxis.  But  it  is  the  microscopical 
examination  of  the  blood  alone  which  enables  us  to  distinguish  leukae- 
mic  swelling  of  the  spleen  from  malarial  or  other  affections.  And  to 
have  a  definite  diagnostic  meaning  the  white  corpuscles  must  be  de- 
cidedly and  permanently  increased  and  altered  in  shape.  It  is,  indeed, 
not  easy  to  draw  a  line  between  leucocytosis,  however  caused,  and 
leukeemia.  Anything  above  100,000  white  cells  to  the  cubic  centi- 
metre is  looked  upon  as  exceeding  the  limit  of  leucocytosis.  But  it  is 
the  character  of  the  elements  of  the  blood,  not  the  mere  number  of 
the  white  cells,  that  positively  determines  the  diagnosis.  The  charac- 
teristic feature  is  the  great  preponderance  of  marrow-cells.  These 
myelocytes  are  generally  large,  highly  granular,  often  irregular,  and, 
stained  with  aniline,  they  show  themselves  as  the  so-called  eosino- 
phile  marrow-cells.  Besides  this,  the  eosinophonic  cells  are  in- 
creased, as  well  as  the  lymphocytes ;  though  this  increase  is  very 
slight  in  proportion  to  the  enormous  number  of  the  myelocytes. 
There  are  all  forms  of  intermediate,  irregular  leucocytes.  There  is 
only  a  slight  decrease  in  the  number  of  the  red  cells,  notwithstanding 
the  enormous  increase  of  the  white  cells,  and  among  the  red  cells  are 
many  nucleated  ones.  As  contrasted  with  leucocytosis,  Hayem  and 
Cabot  lay  stress  on  the  fact  that  the  large  white  cells  are  mostly  not 
amoeboid.  These  characters  of  the  blood  distinguish  splenic  leukaemia 
from  splenic  anaemia,  from  pseudo-leukaemia,  and  from  malarial  en- 
largement of  the  spleen.  In  all  these,  moreover,  the  leucocytes,  even 
if  increased,  are  not  markedly  so,  are  not  abnormal  in  appearance, 
and  the  differential  enumeration  gives  a  wholly  dissimilar  result.  The 
red  corpuscles  are  much  more  apt  to  be  decreased  ;  there  is,  indeed, 
more  or  less  anaemia.  In  lymphatic  leukcemia  there  is  marked  swelling 
of  the  lymphatic  glands,  while  the  spleen  is  but  slightly,  or  not  at  all, 
enlarged.  The  leucocytes  are  also  markedly  increased,  but  not  to 
the  extent  found  in  splenic  leukaemia,  and  they  are  almost  entirely 
lymphocytes.  Polynucleated  leucocytes,  so  common  in  splenic 
leukaemia,  are  few,  only  about  three  per  cent. ;  myelocytes  are  mostly 
absent ;  and  so  are  nucleated  red  corpuscles.  In  the  medullary  form 
of  leukaemia,  rare  except  in  combination  with  the  splenic,  there  is 


DISEASES  OF  THE  BLOOD.  749 

obvious  abnormal  condition  of  the  spleen  and  the  lymphatic  glands, 
the  blood  shows  marrow-cells  in  enormous  numbers  and  in  all  stages 
of  development,  many  very  granular  or  undergoing  multiplication  by 
indirect  nuclear  division. 

In  comparatively  rare  instances  leukaemia  runs  an  acute  course, 
varying  in  duration  from  one  to  nine  weeks  to  its  termination.  It 
may  be  of  the  splenic,  splenic  medullary,  or  lymphatic  variety.  The 
disease  generally  sets  in  with  chills,  the  fever  is  irregular,  the  spleen 
or  the  lymphatic  glands  enlarge,  and  a  hemorrhagic  tendency  mani- 
fests itself.  The  blood  condition  is  the  same  as  in  the  chronic  form, 
especially  the  lymphatic  variety,  and  the  small  uninucleated  leucocytes 
are  immensely  increased.  It  is  almost  invariably  fatal.  Bramwell  ^ 
has  reporte.d  a  case  recovering  rapidly  under  quinine. 

Lymphadenoma. — As  regards  the  symptoms,  the  closest  similarity 
to  leukaemia  is  presented  by  the  affection  described  as  lymphadenoma, 
pseudo-leukaemia,  or  Hodgkin''s  disease.  It  consists  in  an  enlargement 
of  the  lymphatic  glands  of  the  body,  often  with  lymphoid  growths  in 
other  parts,  which  soon  becomes  complicated  with  weakness  and  signs 
of  cachexia,  with  diarrhcea,  with  dropsy,  with  cardiac  palpitation, 
shortness  of  breath  and  attacks  of  suffocation,  with  tendency  to  pro- 
fuse bleedings  and  to  bedsores,  and  leads  usually,  in  the  course  of 
not  many  months,  or,  at  farthest,  of  a  few  years,  to  death.  There  is 
often  a  sense  of  fulness  in  the  abdomen,  attended  with  violent  pains  ; 
the  temperature  in  advanced  cases  shows  mostly  an  evening  rise. 
Some  of  the  superficial  lymphatics  are  first  affected,  others  follow ; 
the  disorder  then  extends  more  decidedly,  the  spleen  and  the  liver 
increase  in  size,  other  organs,  too,  may  become  involved,  and  lymphoid 
tumors  develop  in  various  parts  of  the  body  ;  but  among  the  internal 
organs  the  spleen  is  the  one  most  constantly  disturbed. 

The  disease  generally  begins  in  the  cervical  glands ;  far  less  fre- 
quently does  it  show  itself  first  in  the  inguinal  or  in  the  axillary 
glands  ;  still  less  frequently  in  the  bronchial  or  in  other  internal  glands. 
The  affection  occurs  much  oftener  in  men  than  in  women.  It  mostly 
happens  in  males  between  the  ages  of  ten  and  thirty-five  and  of  fifty 
and  sixty ;  it  is  not  very  uncommon  in  young  children.  Its  cause  is 
unknown ;  it  certainly  has  no  definite  connection  with  either  scrofula 
or  syphilis.  In  infancy  the  disease,  as  von  Jaksch  shows,  occurs  as 
a  combination  of  a  grave  anaemia  with  marked  loucocytosis. 

The  blood  shows  some  deficiency  in  red  globules,  but  otherwise 
no  constant  alteration.     Slight  increase  of  leucocytes  has  been  occa- 


'  AiiiiMuiu,  Edinburgh,  1899,  p.  164. 


750  MEDICAL   DIAGNOSIS. 

sionally  noticed,  especially  during  the  later  stages  ;  the  white  corpuscles 
are  generally  small  and  uninucleated  or  multinucleated.  Myelocytes 
are  absent.     The  haemoglobin  is  reduced. 

It  is  this  difference  in  the  state  of  the  blood  that  makes  the  chief 
distinction  between  pseudo-leukaemia  and  leukaemia,  in  which  there 
may  be  glandular  enlargements.  Rare  cases  of  diffused  lymphatic 
cancer  closely  resemble  Hodgkin's  disease ;  so  closely  that  they  are 
undistinguishable,  except  by  the  history  of  the  case  and  by  a  micro- 
scopical examination  of  any  of  the  tumors  that  may  have  been  re- 
moved ;  the  spleen  is  not  involved,  while  the  organs  contiguous  to  the 
glandular  cancer  are  likely  to  be  more  rapidly  implicated.  In  sarcoma 
of  the  lymphatic  glands  the  disease  is  at  first  strictly  local,  and  then,  if 
it  spread,  invades  not  the  lymphatic  tissues  specially,  but  any  part  of 
the  body ;  the  enlarged  glands  do  not  move  freely  on  each  other  as 
they  do  in  lymphadenoma ;  and  the  blood-changes  are  those  of  a 
secondary  anaemia.  Perhaps  the  fact  Cabot  regards  as  of  much  value 
— that  in  cancerous  anaemia  the  megaloblasts  are  always  fewer  in 
number  than  the  normoblasts — may  here  prove  of  decided  use.  Local 
gland  lymphomas  are  separated  from  Hodgkin's  disease  by  their  local 
character,  by  their  want  of  extension,  and  by  the  absence  of  marked 
cachexia.  Scrofulous  or  tuhercidous  glands,  unlike  lymphadenoma, 
enlarge  rapidly,  have  thickened  tissue  around  them,  and  are  apt  to 
undergo  cheesy  degeneration,  or  to  soften  and  suppurate.  More- 
over, they  are  associated  with  the  presence  of  tubercle  bacilli,  and 
mostly  affect  the  submaxillary  glands.  The  anterior  cervical  glands 
are  the  ones  chiefly  and  primarily  affected  in  Hodgkin's  disease.  In 
splenic  anaemia,  or  splenic  pseudo-leukcemia,  as  it  is  less  appropriately 
called,  we  have  the  same  condition  of  the  blood  as  in  Hodgkin's 
disease,  save  that  there  is  mostly  a  much  greater  decrease  in  the  red 
blood-corpuscles,  and  nothing  absolutely  distinguishes  it  except  the 
absence  of  enlarged  external  lymphatic  glands,  and  the  more  decided 
increase  of  the  spleen,  which,  though  greatly  enlarged,  is  unaltered 
in  shape.  There  may  be  some  enlargement  of  the  retro-peritoneal 
glands,  and  there  is  variable  fever,  as  in  other  grave  anaemias.  In 
some  cases  of  Hodgkin's  disease  fever  is  a  prominent  symptom,  and 
this  may  be  of  intermittent  type,  giving  rise  to  the  belief  that  we  are 
dealing  with  a  malarial  affection;  recurring  chills  make  error  still 
more  likely. 

In  the  early  stages  of  lymphadenoma  a  diagnosis  is  impossible,  and 
we  are  at  a  loss  to  account  for  the  increasing  signs  of  cachexia,  until 
the  involvement  of  the  lymphatic  glands  in  rapid  succession,  and 
their  quick  growth,  or  the  speedy  formation  of  other  lymphoid  tumors 


DISEASES  OF  THE  BLOOD.  751 

under  the  skin  or  in  other  parts  of  the  body,  clear  up  all  doubt. 
There  will  also  be  great  uncertainty  in  all  those  instances  in  which 
the  growths  happen  first  in  internal  glands  or  structures, — as  in  the 
bronchial  glands  and  the  mediastinum,  producing  severe  bronchitis, 
extreme  dyspnoea,  and  signs  of  venous  stagnation  in  the  veins  of  the 
upper  part  of  the  body ;  or  as  in  the  glands  around  the  biliary  ducts, 
giving  rise  to  jaundice  ;  or  as  in  growths  of  the  spinal  cord  leading  to 
paraplegia, — until  the  external  swellings  explain  the  case.  The  kidney 
is  not  an  organ  that  often  suffers  primarily ;  the  occurrence  of  more 
than  a  mere  trace  of  albumin  shows  that  it  has  become  implicated 
from  parenchymatous  changes  or  disseminate  lymphoid  growths. 
Lymphadenoma  may  run  an  acute  course,  with  fever  and  marked 
hemorrhagic  tendency, 

Addison's  Disease. — While  seeking  for  the  explanation  of  puz- 
zling cases  of  ansemia,  Addison  discovered  that  a  peculiar  anaemia 
always  occurs  in  connection  with  a  diseased  condition  of  the  supra- 
renal capsules,  and  is  characterized  by  distressing  languor  and  great 
general  prostration,  remarkable  feebleness  of  the  heart's  action,  loss 
of  appetite,  obstinate  vomiting,  and  a  singular  alteration  of  the  skin. 
This  consists  in  a  dingy  or  smoky  hue  of  the  surface  ;  or  the  color 
may  be  of  a  deep  amber  or  chestnut  brown,  or  the  altered  skin  may 
have  a  bronzed  tinge.  The  change  of  color  begins  on  exposed  parts, 
such  as  the  face  and  neck  and  the  back  of  the  hands,  and  deepens 
first  there ;  but  we  also  soon  find  it  marked  in  parts  which  are  nat- 
urally the  seat  of  much  pigment,  such  as  the  axillae,  the  groins,  and 
the  areolae  of  the  nipples.  It  is  also  marked  around  the  umbilicus, 
on  the  penis,  and  on  the  scrotum,  and  is  dependent  upon  a  layer  of 
pigment  in  the  rete  mucosum.  There  are  also  deposits  of  pigment  on 
the  lips  and  gums  and  other  mucous  membranes.  The  skin  remains 
soft  and  smooth,  and  becomes  in  large  portions  uniformly  discolored, 
gradually  deepening,  and  often  presenting  a  hue  on  the  face  and 
hands  like  that  of  a  mulatto.  Any  irritation  of  the  skin  is  followed 
by  dark  streaks.  Discoloration  in  patches  is  both  less  constant  and 
less  significant  than  extensive  alteration  of  hue ;  yet  the  darkening 
in  undoubted  cases  may  occur  in  patches,  which  are  usually  most 
obvious  on  the  face  or  the  superior  extremities.  The  patient  may 
seem  at  first  sight  to  be  jaundiced ;  but  the  pearly  whiteness  of  the 
conjunctiva  soon  dispels  such  an  idea.  The  nails  are  pale  and  bluish  ; 
the  tongue  may  have  patches  of  dark  color ;  the  body  and  breath  at 
times  exhale  an  offensive  odor.  The  blood  does  not  undergo  any 
characteristic  alteration.  It  shows  a  more  or  less  marked  decrease 
of  the  red  corpuscles,  without  any  change  in  the  white.     These  are 


752  MEDICAL   DIAGNOSIS. 

sometimes  found  to  contain  black  pigment  granules.      The  haemo- 
globin is  but  little,  if  at  all,  below  the  normal  average. 

With  reference  to  the  other  symptoms,  the  most  conclusive  of 
them  are  remarkable  prostration,  generally  without  any  marked  waste 
of  the  body,  feebleness  of  heart  action  and  of  pulse,  and  obvious 
anaemia.  In  most  cases,  but  far  from  in  all,  these  symptoms  precede 
the  discoloration  of  the  skin  ;  and  they  are  not  infrequently  associated 
with  pain  in  the  back  and  with  nausea  and  vomiting  and  attacks  of 
diarrhoea,  with  breathlessness  upon  exertion,  with  vertigo,  and  with 
dimness  of  sight  or  impaired  hearing.  A  peculiar  odor  of  the  body, 
like  that  perceived  in  the  colored  race,  was  observed  in  two  cases 
placed  on  record  by  Mr.  Hutchinson.  In  the  later  stages  of  the 
malady  the  temperature  falls  below  the  norm.  The  pulse,  in  place  of 
being  feeble,  may  be  of  strikingly  high  tension,  owing  to  the  absence 
of  the  secretion  of  the  suprarenals,  and  we  may  recognize  disease  of 
these  organs  from  this  high  tension  even  when  no  pigmentation  exists, 
provided  we  are  able  to  exclude  other  causes  for  a  high-tension  pulse. 

Death  may  take  place  gradually  from  the  constantly  growing 
asthenia ;  or  it  may  occur  suddenly,  and  where  the  amount  of  pros- 
tration does  not  appear  so  excessive  as  to  foreshadow  it.  According 
to  the  elaborate  researches  of  Wilks,  the  destruction  of  the  capsules  is 
dependent  upon  a  peculiar  scrofulous  degeneration  ;  and  this  view  of 
the  tubercular  nature  of  Addison's  disease  is  now  very  generally 
held.^  Should  this  prove  to  be  correct, — should  it  appear,  in  other 
words,  that  the  nature  of  the  disease  of  the  adrenals  influences  the 
symptoms  more  than  the  mere  fact  of  their  being  diseased, — it  would 
explain  why  in  some  cases  of  absence  of  the  glands,  or  of  their  can- 
cerous degeneration  or  suppuration,  no  signs  of  Addison's  disease  ex- 
isted. Yet  tuberculous  disease  of  the  adrenals,  with  tubercle  bacilH 
in  the  caseous  glands,  has  been  found  without  bronzing  of  the  skin.^ 
Many  of  the  symptoms  of  the  fully  developed  malady  may  be  due  to 
the  imphcation  of  the  nervous  branches,  derived  from  the  sympathetic 
and  the  pneumogastric,  which  go  to  the  glands.  Indeed,  the  idea  of 
the  primary  seat  of  the  disease  in  the  abdominal  sympathetic  nerve  is 
strongly  advocated  by  some  observers.  Bramwell  calls  attention  to 
the  frequency  of  coexisting  atrophy  of  the  heart. 

Now,  in  the  diagnosis  of  Addison's  disease  the  alteration  of  the 
color  of  the  skin  plays  so  important  a  part  that  we  must  inquire 


1  See,  for  analysis  of  cases,  Gilman  Thompson,  Transact,  of  Assoc,  of  Amer. 
Physicians,  1893. 

''■  As  in  the  case  of  Ballengliien,  Journ.  des  Sci.  Med.  dc  I^ille,  1888. 


DISEASES  OF  THE  BLOOD.  753 

whether  it  or  something  very  hke  it  may  not  liappen  in  other  con- 
ditions. In  persons  long  exposed  to  the  sun  a  bronzing  of  the  face  and 
neck  and  arms  occurs  ;  but  it  is  extremely  uniform  ;  there  is  a  striking 
contrast  between  it  and  the  parts  that  are  not  exposed,  including  such 
as  we  find  greatly  affected  in  Addison's  disease,  the  flexures  of  the 
joint,  the  scrotum,  the  textures  around  the  nipple  and  the  umbilicus. 
Moreover,  there  is  often  robust  rather  than  impaired  health.  In 
persons  who,  in  addition  to  exposure,  are  of  uncleanly  habits  and  in- 
fested with  verm'in,  especially  in  elderly  persons,  a  discoloration  of 
the  skin  happens  at  various  portions  of  the  body,  often  deepest  on  the 
chest,  the  abdomen,  and  the  back,  which. is  readily  mistaken  for  the 
bronzing  of  Addison's  disease.  But  in  this  vagrants'  disease  the  dis- 
coloration is  in  the  superficial,  not  in  the  deeper  layers  of  the  epi- 
dermis, and  the  dark  cuticle  is  harsh  and  raised,  not  soft  and  smooth. 
Then  alkaline  baths  and  washing  with  soap  will  greatly  diminish  the 
deepened  hue.  A  similar  bronzing  of  long  standing,  though  of  doubt- 
ful origin,  is  sometimes  met  Avith.^ 

During  exhausting  lactation,  or  in  pregnancies  attended  with  much 
constitutional  disturbance,  there  may  be  marked  discoloration  of  the 
skin  ;  yet  it  is  not  most  obvious  on  the  face,  and  the  circumstances 
of  the  case  are  important  aids  in  the  diagnosis.  So  is  the  history 
in  those  instances  in  which  a  bronze  hue  is  hereditary^"  or  in  which 
a  very  deceptive  discoloration  attends  tubercular  peritonitis  or  chronic 
diseases  of  the  liver,  especially  cirrhosis  ;  or  follows  yellmv  fever,  or  the 
malarial  fevers.  In  these  diseases,  too,  the  discoloration  is  not  so 
great,  and  it  is  not  marked  at  the  sites  most  affected  in  x4.ddison's  dis- 
ease. Greenhow  has  pointed  out  how  certain  very  long  standing  in- 
stances of  phthisis  exhibit  an  appearance  exactly  like  that  of  the 
earlier  stages  of  Addison's  disease.  Yet  the  abnormal  pigmentation 
does  not  deepen  or  increase,  and  the  symptoms  remain  only  those  of 
the  pulmonary  malady.  Stains  on  the  skin  from  pityriasis  versicolor 
or  from  sypjhilis  have  not  the  characteristic  seats  of  Addison's  disease, 
and  they  are  in  patches  and  surrounded  by  healthy  skin,  and  certainly 
the  syphilitic  affection  coexists  with  other  significant  eruptions  or 
signs.  Malcolm  Morris'^  has  called  attention  to  the  mistake  of  jiro- 
nouncing  a  case  of  acanthosis  nigricans  one  of  Addison's  disease.  The 
fact  that  the  processes  in  the  former  are  confined  to  the  upper  layer 
of  the  skin,  and  characterized  by  an  abnormal  development  of  the 


'  Crocker,  Transact.  Clin.  Soc.  Lond.,  vol.  xiv.,  1881  ;  also  Carrington,  ibid. 
''  Medical  Times  and  Gazette,  May,  1871. 
•'  Mi^dicn-rhiniraical  Trnnsrictinnf;,  1894. 

47 


754  MEDICAL  DIAGNOSIS. 

younger  not  yet  cornified  elements  of  the  upper  layers, — the  so-called 
prickle-layer, — will  serve  to  separate  it  pathologically  from  the  sec- 
ondary and  relatively  unimportant  changes  of  the  skin  that  attend  the 
course  of  the  latter  affection.  A  chocolate-colored  discoloration  of 
the  whole  surface  of  the  body  has  been  observed  in  a  case  of  psori- 
asis in  which  the  patient  continued  to  take  arsenic  during  a  period  of 
two  and  a  half  years/  In  Recklinghausen's  disease  there  is  pigmenta- 
tion of  the  skin,  often  in  considerable  patches,  but  the  subcutaneous 
tumors  due  to  neuromata,  the  tumors  of  the  skin  "of  the  nature  of 
molluscum  fibrosum,  the  pain,  the  arthralgia,  the  alteration  of  sensa- 
tion, and  the  impaired  mental  activity  characterize  the  affection. 

One  of  the  confusing  points  connected  with  the  diagnosis  of  Addi- 
son's disease  is  that  cases  occur  without  bronzing,  or  with  the  dis- 
coloration of  the  skin  so  slight  as  to  be  a  matter  of  doubt.  Such 
cases  are  generally  in  persons  who  die  before  they  have  had  the  dis- 
ease any  length  of  time.  If  the  altered  hue  of  the  skin  be  wanting, 
the  complaint  is  undistinguishable  from  pernicious  anoemia,  except  by 
the  characteristic  blood-changes  this  presents.  Other  diseases  of  the 
suprarenal  capsules,  such  as  cancer  and  waxy  disease,  are  also  not  to 
be  separated  from  the  peculiar  affection  of  the  gland  occasioning 
Addison's  disease,  if  bronzing  of  the  skin  be  not  present. 

The  malady,  as  Greenhow  proves,  is  very  rare  except  in  persons 
employed  in  manual  labor.  In  some  instances  it  seems  to  arise  from 
grief  or  protracted  anxiety.  The  disorder  is  a  chronic  one,  generally 
lasting  for  years  ;  but  it  almost  always  destroys  life.  Yet  cases  have 
been  recorded  in  which  most  of  the  symptoms  of  Addison's  disease 
existed  and  which  recovered;  and  certainly  long  remissions  in  the 
symptoms  have  been  not  infrequently  observed,  and  in  these  remissions 
the  discolored  skin  has  lightened.  The  disease  is  occasionally  met 
with  in  young  persons.  Dyson  reports  a  fatal  case  in  a  girl  thuieen 
years  of  age.^ 

Pysemia. — Purulent  contamination  of  the  blood  is  an  affection 
much  more  likely  to  be  met  with  by  the  surgeon  than  by  the  physi- 
cian ;  yet  the  physician  must  be  familiar  with  its  symptoms.  These 
are,  great  depression  of  the  vital  powers,  high  but  irregular  tempera- 
ture, profuse  sweats,  rapid  pulse,'  and  the  formation  of  purulent  de- 
posits in  different  portions  of  the  body.  The  symptoms  may  be  of 
gradual  development ;  but  often  they  set  in  suddenly  with  a  chill,  to 
which  a  fever  of  Ioav  type  soon  succeeds  ;  or  the  shivering  is  followed 


1  Carrier,  Medical  News,  Feb.  3,  1894.  p.  12/ 
^  Quar.  Med.  Journ.,  vol.  iii..  Part  I. 


DISEASES  OF  THE  BLOOD.  755 

by  copious  sweating?  and  the  febrile  phenomena  subsequently  appear. 
A  transient  erythematous  blush  on  the  skin  is  not  unusual. 

The  pyjemic  fever  rarely  lasts  longer  than  a  week,  and  during 
its  continuance  the  temperature  shows  marked  variations.  Yet 
the  disease  is  not  always  alike  in  this  respect ;  for  we  find  not 
only  cases  in  which  the  most  decided  increase  of  heat  is  constantly 
follo^ved  by  an  equally  decided  decrease,  but  also  cases  in  which 
there  are  febrile  attacks  follow^ed  by  intervals  during  which  the 
temperature  is  almost  normal.  Still,  in  all  the  maximum  temper- 
ature is  apt  to  be  very  high,  ranging  from  105°  to  108°.  Pyaemia,  as 
the  physician  meets  with  it,  is  seen  where  sinuses  or  abscesses  exist 
that  have  no  free  vent  for  the  pus ;  or  in  consequence  of  an  infective 
phlebitis  or  arteritis ;  or  in  inflammation  of  the  external  coat  of  ar- 
teries, with  suppuration,  especially  in  the  periarteritis  of  the  thoracic 
aorta ;  or  in  ulcerative  endocarditis ;  or  the  pyaemia  results  from  the 
purulent  breaking  down  of  coagula  in  the  blood-vessels  ;  or  it  may 
supervene  upon  diffuse  cellular  inflammations,  or  upon  puerperal 
fever :  in  fact,  it  will  be  found  under  many  dissimilar  circumstances. 
Micro-organisms  play  an  important  part  in  its  production,  especially 
the  several  varieties  of  the  streptococcus  pyogenes  and  the  staphylo- 
cocci. They  render  the  pus  septic,  and,  under  conditions  favorable 
to  their  development,  diffuse  the  process. 

There  are  several  complaints  with  which  pyaemia  is  likely  to  be 
confounded,  the  chief  of  which  are  typhoid  fever,  rheumatism,  acute 
glanders  or  farcy,  and  acute  affections  of  the  liver. 

It  is  liable  to  be  mistaken  for  typhoid  fever,  on  account  of  the 
adynamic  character  of  the  fever,  and,  it  may  be,  the  occurrence  of 
diarrhoea  and  of  cerebral  symptoms.  But  the  history  of  the  case  is 
very  dissimilar:  there  is  no  eruption,  or,  if  there  be  an  eruption,  it 
consists,  as  Bristowe  so  particularly  points  out,  of  sudamina  sur- 
rounded by  a  zone  of  congestion,  and  is  therefore  not  the  eruption  of 
the  typh-fevers ;  and,  on  the  other  hand,  we  find  in  typhoid  fever 
neither  the  profuse  sweating  nor  secondary  deposits  of  pus,  and  the 
thermometry  of  the  disease  is  very  different.  The  Widal  test  would, 
in  any  instance,  be  of  value. 

The  pain  in  the  joints  and  their  swelling  in  succession,  the  fever, 
and  the  perspirations,  resemble  much  at  times  rheumatic/ever.  But 
the  difference  consists  in  the  greater  severity  of  the  constitutional 
phenomena  caused  by  the  poisoned  blood,  in  the  marked  exhaustion, 
in  the  rigors,  and  in  the  history  not  being  that  of  acute  rheumatism. 
Moreover,  the  frequent  signs  of  formation  of  abscesses  in  internal 
organs  or  around  the  joints,  the  development  of  pustules  on  the  skin. 


756  MEDICAL  DIAGNOSIS. 

and  the  striking  redness  of  the  tumid  joints  assist  materially  in  the 
diagnosis. 

Acute  glanders  or  acute  farcy  is  a  disease  scarcely  distinguishable 
from  pysemia,  since  it  occasions,  for  the  most  part,  the  same  manifes- 
tations. The  knowledge  that  the  patient  who  has  apparently  pyaemic 
symptoms  has  been  working  among  horses ;  the  ulceration  of  the 
mucous  membrane  of  the  nose,  and  the  fetid  discharge  proceeding 
from  it,  which  occurs  in  acute  glanders  and  is  apt  to  be  associated 
with  nasal  hemorrhages,  and  with  an  erysipelatous  rash  spreading  to 
the  cheek  and  forehead  and  with  enlargement  of  the  lymphatic  glands 
in  the  vicinity  of  the  affected  mucous  membrane, — afford  us  the 
means  of  discrimination.  Then  we  fmd  a  peculiar  tuberculated  or 
pustular  eruption,  resembling  smallpox,  upon  the  skin  ;  and  in  farcy 
the  lymphatic  glands  and  vessels  specially  suffer.  But  most  significant 
are  the  distinct  history  of  the  contagion,  the  detection  of  the  bacillus 
mallei  in  the  discharge,  and  the  inoculation  test  in  guinea-pigs  pro- 
ducing a  characteristic  swelling  of  the  testicles  followed  by  suppuration. 

Acute  affections  of  the  liver  resemble  pyaemia  on  account  of  the 
jaundice  that  may  attend  the  latter  disorder;  the  history  of  the  case, 
the  rigors,  the  sweats,  and  the  purulent  deposits  distinguish  it.  Yet 
it  must  be  remembered  that  suppurative  inflammation  of  the  portal 
veins  and  metastatic  abscesses  of  the  liver  happen,  giving  rise  to 
pyaemia. 

The  secondary  deposits,  or  metastatic  or  embolic  abscesses,  take 
place  in  the  parenchymatous  organs,  particularly  in  the  lungs  and  the 
liver ;  in  the  synovial  sacs,  in  muscles,  or  in  areolar  tissue,  especially 
in  that  under  the  skin.  They  are  mostly  due  to  fragments  of  septic 
thrombi  that  have  become  centres  of  suppurative  change.  If  the 
altered  blood  coagulate  in  the  arteries,  and  the  infected  clot  disin- 
tegrate, occasioning  deposits  in  solid  organs,  as  in  the  liver  or  the 
spleen,  we  may  have  symptoms  arising  like  those  of  ordinary  pyaemia. 
Indeed,  in  the  arterial  pyoemia,  as  it  has  been  called,  rigors,  febrile 
symptoms  and  sweating,  and  pains  in  the  joints  are  observable. 
In  connection  with  the  obscure  febrile  condition,  the  liver  and  the 
spleen  are  often  observed  to  increase  in  size  slowly.^  The  heart  may 
or  may  not  be  affected ;  ulcerative  endocarditis  is  often  present. 
Hayem  has  pointed  out  •  that  there  may  be  capillary  embolism  in 
pyaemia,  not  to  be  recognized  except  by  the  microscope.  It  may  be 
one  of  the  causes  of  the  so-called  idiopathic  pycemia  in  which  the 
source  of  infection  is  not  apparent. 


^  Samuel  Wilks,  Guy's  Hospital  Reports,  vol.  xv.,  3cl  Series. 


DISEASES  OF  THE  BLOOD.  757 

There  is  a  form  of  pysemia,  called  by  Leiibe '  spontaneous  septico- 
pycemia,  which  comes  on  without  obvious  cause,  or  is  perhaps  pre- 
ceded by  a  fall  or  a  slight  skin  wound,  in  which  the  symptoms  of 
pyaemia  become  developed  with  pain  and  tenderness  in  joints  and 
muscles,  ecchymosis  of  the  conjunctiva,  vesicles  in  the  skin  contain- 
ing blood,  extremely  high  temperature,  swelling  of  the  spleen,  albu- 
minous urine,  pleurisy  or  perhaps  signs  of  endocarditis  or  pericarditis, 
stupor,  delirium,  cramps,  and  finally  involuntary  discharges  and  coma. 
The  disease,  resembling  the  typh-fevers,  or  ulcerative  endocarditis,  is 
to  be  distinguished  only  by  the  association  of  the  symptoms. 

The  description  of  pyaemia  given  represents  it  as  an  acute  affec- 
tion, and  so  it  almost  always  is.  Yet  there  are  cases  much  slower 
in  their  course,  and  extending  over  months.  These  chronic  or  re- 
lap>sing  instances  of  the  disease  have  been  described  by  Paget.^  The 
symptoms  presented  are  the  same  as  in  the  acute  disorder ;  but  the 
local  evidences  of  the  complaint  are  more  often  seated  in  different 
parts  of  the  same  tissues,  and  less  frequently  in  internal  organs.  The 
malady  is  not  nearly  so  perilous  as  is  the  acute  disease. 

Septicsemia. — This  is  a  poisoned  state  of  the  blood,  produced 
especially  by  animal  poisons,  such  as  the  bites  of  venomous  serpents, 
or  the  absorption  of  putrid  matters  that  have  been  generated  in  the 
economy,  or  by  their  inoculation.  It  may  be  seen  after  injuries  and 
wounds,  or  in  the  puerperal  state.  The  continued  exposure  to  the 
breathing  of  foul  air  and  of  septic  gases  will  also  occasion  septicaemia. 
There  are  no  discoverable  foci  of  suppuration,  but  the  bacteria  occa- 
sioning the  sepsis  are  in  the  main  the  same  as  those  of  pyaemia. 
Toxines  and  ptomaines  have  much  to  do  with  the  process. 

The  symptoms  of  the  blood-poisoning  vary  somewhat  with  the 
individual  poison  that  has  occasioned  it.  They  are,  as  a  rule,  the 
symptoms  of  pyaemia,  except  that  secondary  pus-formations  belong  to 
the  former  rather  than  to  the  latter ;  and  the  same  may  be  said  of 
embolism  and  its  results.  Rigors  are  frequently  observed.  In  many 
instances  the  altered  condition  of  the  blood  leads  to  great  prostration, 
to  hemorrhages  from  internal  organs,  to  petechiae,  to  delirium  and 
coma,  to  extreme  rapidity  of  pulse,  to  rapidly  developed  fever  with 
high  temperature,  to  enlargement  of  the  spleen,  to  cough  and  bron- 
chial catarrh,  and  to  gastric  and  intestinal  disorders.  The  blood 
shows  the  white  corpuscles  almost  always  in  marked  excess,  although 
not  altered  in  character  as  they  are   usually  in  leukaemia;    the    red 


1  Archiv  fur  klin.  Med.,  xxii.,  1878. 

''■  St.  Bartholomew's  Hospital  Reports,  vol.  i. 


758  MEDICAL  DIAGNOSIS. 

globules  are  diminished.^  The  bacterial  types  characteristic  of  the 
forms  of  septicaemia  are  generally  demonstrable  by  microscopic  exam- 
ination and  by  culture  experiments.  Staphylococcsemia  has  been 
often  recognized,  and  a  number  of  instances  of  pyocyaneus  bacilli- 
gemia  have  been  recorded.^ 

Malarial  Septicmmia. — Since  the  discovery  of  the  plasmodium  ma- 
laria:, malaria  has  entered  the  list  of  infectious  diseases,  and  it  has 
become  recognized  that  it  may  cause  a  form  of  septicaemia.  Klebs 
asserts  that  he  has  found  flagellate  protozoa  in  the  febrile  stage  of 
influenza,  but  this  observation  has  not  been  confirmed. 

Typhoid  Septiccemia. — Several  observers,  especially  in  Italy ,^  have 
reported  cases  of  typhoid  septicaemia  without  the  accustomed  altera- 
tions in  the  intestinal  tract.  The  diagnosis  was  based  upon  bacterio- 
logical examination.  Dogliotti  also  reported  a  case  which  had  fever, 
enlarged  spleen,  and  copious  eruption  of  typhoid  roseola  extending 
over  the  entire  body.  There  was  profuse  diarrhoea.  Cultures  of 
blood  from  the  fmger  and  from  a  vein  in  the  arm  remained  sterile ; 
but  cultures  taken  from  the  blood  of  the  papules  developed  bacilli 
having  all  the  characters  of  the  typhoid  bacilli.  At  the  post-mortenl 
examination  no  ulcers  or  cicatrices  were  found  in  the  intestine.  The 
conclusion  is  that,  besides  the  familiar  form  of  abdominal  typhoid, 
there  is  another,  identical  in  every  way  except  that  it  has  no  intestinal 
or  lymphatic  localization;  the  bacilli  select  the  skin  in  preference. 
Septicasmic  typhoid  then  presents  the  following  characters  :  an  irreg- 
ular fever,  not  typical  as  that  of  ileo-typhoid ;  the  absence  through 
the  entire  illness  of  visceral  complications  and  of  symptoms  pertain- 
ing to  the  digestive  system ;  the  presence  in  the  circulating  blood, 
and  especially  in  the  blood  extracted  from  the  rash,  of  a  bacillus  pre- 
senting the  characters  of  the  typhoid  bacillus.^ 

Pygemia  and  septicaemia  have  shifted  greatly  from  their  old  signifi- 
cance. We  know  much  more  of  direct  infection  and  how  foci  of  sup- 
puration are  set  up  in  various  parts  of  the  body.  Another  set  of 
symptoms  is  occasioned  when  the  products  of  the  micro-organisms 
only,  the  so-called  toxines,  are  absorbed  by  the  blood;  here  fever, 
prostration,  and  various  nervous  phenomena  are  caused.  This  condi- 
tion has  been  termed  saproemia,  to  distinguish  it  from  septicaemia,  in 


1  Report  of  the  Committee  of  the  Pathological  Society  of  London,  Transac- 
tions, 1879. 

^  See  paper  by  Brill  and  Libman,  Amer.  Journ.  Med.  Sci.,  Aug.  1899. 

3  See  Guido  Bariti,  Riforma  Medica,  1887. 

*  Translation  in  the  Pacific  Medical  Journal,  vol.  xxxviii.  p.  203  ;  also  Dogli- 
otti, Gazz.  Med.  di  Torino,  1894. 


DISEASES  OF  THE  BLOOD.  759 

which  the  infective  agent  is  actually  present  in  the  blood.  Occa- 
sionally pathogenic  micrococci  may  be  present  in  the  body  without 
giving  rise  to  either  suppuration  or  septic  disease.  The  tissue-cells, 
especially  those  of  the  spleen  and  the  kidney,  play  a  very  important 
part  in  tha  destruction,  and  the  leucocytes  are  also  active  in  the 
warfare. 

Thrombosis  and  Embolism. — Although  in  connection  with 
endocarditis,  with  obstruction  of  the  cerebral  arteries,  and  with  dis- 
eases of  the  kidney,  the  phenomena  of  embolism  have  been  described, 
it  may  serve  a  useful  purpose  to  view  here  connectedly,  though  chiefly 
in  their  diagnostic  bearing,  some  of  the  results  of  the  formation  of 
the  clots  in  large  vessels  or  in  the  heart,  and  of  their  being  carried 
along  with  the  current  of  the  blood  and  driven  into  remote  vessels, — • 
the  results,  therefore,  of  thrombosis  and  of  embolism. 

In  the  veins  thrombi  may  form,  which,  so  long  as  they  do  not  pro- 
duce obstruction  of  the  canal,  give  rise  to  no  marked  signs.  A  slight 
hardening  and  pain  on  pressure  if  the  coagulum  be  in  one  of  the 
more  superficial  veins,  their  enlargement  if  the  clot  be  in  a  deeper 
vein,  are  apt  to  be  the  only  evidences  of  the  disordered  condition. 
But  when  the  occlusion  is  considerable,  and  especiahy  when  the  col- 
lateral circulation  is  insufficient,  oedema  is  developed,  which  may  be 
attended  with  very  great  tenderness  of  the  swollen  part,  and,  if  the 
impediment  be  of  long  duration,  with  changes  in  the  nutrition  of  the 
structures  sufficient  to  produce  phlegmonous  inflammation.  •  These 
phenomena  are  encountered  in  milk-leg,  phlegmasia  alba  dolens^  as  we 
see  it  in  puerperal  fever,  in  typhoid  fever,  in  influenza,  and  in  pneu- 
monia ;  though  it  is  by  no  means  settled  whether  the  thrombosis  is 
primary  from  the  infected  blood,  or  the  result  of  an  infective  phlebitis. 
We  may  have,  also,  a  thrombo-phlebitis  as  well  as  a  thrombo-arte- 
ritis,  showing  itself  as  an  acute  infective  fever  without  anatomical 
localization,  except  in  the  blood-vessels.  In  some  cases  profuse 
hemorrhages  happen  as  a  consequence  of  the  stoppage  in  the  vein, — 
as  cerebral  hemorrhages  produced  by  thrombosis  of  the  sinus,  or,  as  in 
a  case  referred  to  by  Virchow,^  as  enormous  hemorrhagic  infiltration 
of  the  subperitoneal  and  subcutaneous  tissues,  as  well  as  of  portions 
of  the  muscles  of  the  abdominal  walls,  the  result  of  a  coagulum  in 
the  external  iliac  vein,  the  epigastric,  and  the  crural  vein.  Thrombosis 
may  occur  in  the  cerebral  sinuses,  without  causing  hemorrhage,  but 
giving  rise  to  pressure  symptoms,  pain,  prominence  of  the  eyes,  and 
oedema ;  it  may  be  followed  by  complete  recovery. 


^  Pathologic  unci  Therapie,  p.  172. 


760  MEDICAL   DIAGNOSIS. 

In  thrombosis  of  the  mesenteric  vessels,  the  symptoms  are  intense  ab- 
dominal pain,  great  tenderness,  vomiting,  abdominal  distention,  and 
often,  if  the  patient  survive  the  shock,  obstruction  of  the  bowels/ 
There  is  an  instance  of  recovery,  the  result  of  an  operation.^ 

In  exhausting  and  toasting  diseases,  blood  may  clot  in  the  veins  with- 
out any  clearly  marked  cause.  Trousseau  called  attention  to  the 
occurrence  of  milk-leg  as  a  symptom  of  gastric  cancer;  and  in  other 
kinds  of  cancer  there  may  be  peripheral  venous  thrombosis ;  so, 
too,  in  Bright's  disease.  Gout  may  cause  phlebitis  and  clotting  in 
the  veins  of  the  body,  as  Sir  James  Paget  has  pointed  out.  Un- 
doubtedly infective  phlebitis  is  a  cause  of  thrombosis  that  is  com- 
mon. But  it  may  be,  in  a  given  case,  extremely  difficult  to  determine 
whether  the  thrombosis  or  the  phlebitis  is  primary.  Again,  we  may 
have  chlorosis  give  rise  to  thrombosis  in  the  cavities  of  the  heart  and 
the  larger  veins,  such  as  the  femorals,  without  phlebitis  preceding  the 
morbid  condition.  The  thromboses  of  chlorosis  are  generally  of  the 
lower  extremities,  and  may  be  successive  and  multiple.  Both  lower 
extremities  are  often  involved.  They  are  supposed  to  be  due  to  the 
feeble  circulation  of  the  impoverished  blood.  But  this  is  not  certain. 
Welsh  ^  suggests  that  the  thrombus  results  from  nutritive  disturbance 
of  the  red  corpuscles  and  their  ready  disintegration,  producing  the 
material  leading  to  a  thrombus.  The  peripheral  thrombi  in  phthisis 
may  be  of  myotic  origin. 

Now,  portions  of  the  clot,  situated  in  any  part  of  the  venous 
system,  may  become,  by  being  broken  off  and  driven  onward  with  the 
circulation,  sources  of  great  danger.  When  coagula  occur  in  the 
venous  system  and  are  wholly  or  in  part  carried  away  with  the  circu- 
lating blood,  if  we  exclude  those  which,  from  their  situation,  could 
only  reach  the  liver,  the  manifestations  of  disturbance  arise  in  the 
heart  or  the  lungs.  Arriving  at  the  right  side  of  the  heart,  the  concre- 
tion, if  large,  or  if  it  become  so  by  serving  as  a  nucleus  for  a  larger 
clot,  occasions  symptoms  of  exhaustion  and  collapse  :  an  intermitting, 
feeble  pulse ;  irregular  and  confused  beating  of  the  heart,  and  cardiac 
sounds  enfeebled  or  lost  over  the  right  side  of  the  organ  ;  rapidly 
developed  distress  in  breathing,  referred,  by  the  sufferer,  to  the  heart,"^ 
and  signs  of  asphyxia,  though  all  the  time  the  patient  is  taking  deep 
inspirations  ;  great  agitation  ;  and  a  swollen  state  of  the  veins  of  the 


1  Koester,  Deutsche  Medicin.  Wochenschrift,  May  26,  1898. 

^  Gordon,  British  Medical  Journal,  June  4,  1898. 

^  Article,  "Thrombosis,"  AUbutt's  System  of  Medicine,  vol.  vi.,  1899. 

♦  B.  W.  Richardson,  Medical  Times  and  Gazette,  Nov.  1868. 


DISEASES  OF  THE  BLOOD.  761 

body.  Death  may  then  take  place  suddenly  if  a  portion  of  tlie  clot 
separate  and  obstruct  the  pulmonary  artery/ 

But  the  mode  of  death,  and  the  symptoms  preceding  it,  in  embo- 
lism of  the  pulmonary  artery,  are  not  always  the  same,  and  depend 
much  upon  the  size  of  the  embolus  and  where  it  is  arrested.  A  large- 
sized  clot,  whether  it  be  merely  part  of  one  occupying  the  right  heart, 
or  be  washed  at  once  into  the  pulmonary  artery,  will  occasion  the 
same  signs  as  those  mentioned  as  indicative  of  a  large  clot  in  the  right 
side  of  the  heart ;  the  craving  for  air  is  particularly  intense,  and  this 
craving  is  increased  by  every  movement  of  the  body ;  the  muscular 
debility,  the  lowered  temperature,  the  cyanosed  look,  the  turgid  veins 
of  the  neck  and  their  undulations,  the  increased,  irregular  cardiac 
impulse,  the  disturbed  respiration  and  disordered  general  circulation, 
are  also  noticed ;  and  in  some  cases  a  systolic  murmur,  and,  where 
the  case  is  at  all  protracted,  vertigo,  albuminuria,  and  oedema  of  the 
limbs,  may  be  observable.  The  intellect  remains  clear.  As  regards 
the  pulmonary  phenomena  proper,  collapse  of  the  lung,  hemorrhagic 
effusions  or  so-called  infarctions,  oedema,  or  capillary  bronchitis  are 
likely  to  happen,  except  in  those  instances  in  which  the  principal 
kunks  of  the  pulmonary  artery  are  blocked  up  and  almost  instanta- 
neously asphyxia  ensues.  If  the  fragments  be  very  small,  the  amount 
of  dyspnoea  is  not  great,  nor  are  the  symptoms  of  asphyxia  marked ; 
and  inflammations  of  the  parenchyma  of  the  lungs  may  take  place, 
occasioning  often  secondary  obstructions  and  metastatic  abscesses  in 
the  lungs,  especially  when  caused  by  infective  emboli. 

Blood  coagulates  in  the  arteries  in  connection  with  gangrene,  as  in 
diabetic  gangrene,  and  ulceration.  Again,  inflammation,  especially 
infective,  or  sclerotic  or  atheromatous  disease  of  the  coats  of  the  arte- 
ries may  lead  to  the  local  development  of  thrombi ;  so,  it  is  thought, 
may  feeble  action  of  the  heart  with  increased  coagulability  of  the  blood. 
Arterial  thrombosis  has  much  the  same  symptoms  as  embolism  of  the 
artery,  but  the  interference  with  the  circulation  is  less  sudden  and 
intense,  the  signs  of  obstruction  change  less  rapidly,  and  we  often  find 
a  cause  for  the  arterial  thrombosis  in  marked  arteriosclerosis.  Should 
the  case  persist,  muscular  atrophy  and  trophic  disturbance  become 
noticeable. 

Still,  the  most  important  phenomena  connected  with  obstruction 
of  arteries  are  those  of  coagula  being  washed  into  them  ;  the  phe- 
nomena of  embolism,  therefore,  rather  than  those  of  thrombosis.  The 
manifestations  of  embolism  are  distinguished  from  those  of  the  mere 


'  As  in  a  case  recorded  by  Druitt,  Med.  Times  and  Gazette,  July,  1862. 


762  MEDICAL   DIAGNOSIS. 

formation  of  clots  by  what  is  always  the  most  significant  sign  of 
embohsm, — the  suddenness  of  the  phenomena.  And  in  point  of  fact 
the  symptoms  arise  less  often  as  the  result  of  any  of  the  conditions 
mentioned  that  occasion  coagulation  than  in  consequence  of  deposits 
and  excrescences  which  are  seated  on  the  valves  of  the  left  side  of  the 
heart,  portions  of  which  deposits  are  carried  away  by  the  circulating 
blood  into  remote  parts.  When  these  bodies  become  impacted  in  a 
vessel  the  caliber  of  which  is  such  that  it  does  not  permit  them  to 
pass  on,  we  find  rapid  changes  taking  place  in  the  portions  of  the 
body  supplied  by  the  obstructed  artery, — coldness,  pallor  of  the  parts, 
a  local  angemia,  diminished  functional  activity  ;  and  if  the  first  obstruc- 
tion be  followed  by  others,  and  the  collateral  circulation  cannot  be 
established,  local  death  and  gangrene  ensue. 

All  these  changes  are,  of  course,  discernible  only  in  external 
parts,  especially  in  the  extremities ;  the  disturbances  of  function  are 
the  most  obvious  signs  where  the  internal  organs  are  the  sufferers. 
If  the  emboli  be  driven  to  the  brain,  we  have  often  softening  as  the 
final  result,  and  this  may  be  preceded  by  disorder  of  intellect,  without 
motor  disturbances,  and  by  severe  attacks  of  vertigo  in  cases  in  which 
merely  the  smaller  arteries  supplying  the  cerebral  cortex  are  obstructed. 
But  where,  as  is,  indeed,  the  most  common  seat  of  emboli,  the  arteries 
of  the  fissure  of  Sylvius  are  clogged,  the  phenomena  are  those  of  apo- 
plectic hemiplegia,  and  the  palsy  affects  the  whole  of  one  side  of  the 
body.  The  brain  may  also  suffer  from  the  seat  of  the  obstruction 
being  in  the  carotids ;  indeed,  of  all  organs  the  effects  of  embolism 
are  most  plainly  perceptible  in  the  brain.  The  presence  of  emboli  in 
the  splenic,  renal,  hepatic,  and  mesenteric  arteries  is  generally  only  to 
be  inferred  from  the  history  of  the  case,  and  does  not  occasion  any 
clearly  discernible  signs.  But  tenderness,  enlargement  of  the  spleen, 
and  pain  in  the  splenic  region  in  splenic  embolism,,  or  disordered  secre- 
tion of  urine  and  pain  in  the  loins  in  embolism  of  the  renal  artery,  or 
jaundice  in  embolism  of  the  vessels  of  the  liver,  may  be  very  marked. 

The  occurrence  of  pain  in  these  cases  of  internal  embolism  must 
not  be  overlooked ;  and  in  embolism  of  the  arteries  of  the  extremi- 
ties pain  is  a  symptom  of  still  greater  prominence.  It  may  be  like  a 
violent  neuralgia,  or  so  constant  that  it  is  mistaken  for  rheumatism ; 
and,  as  happened  in  the  case  of  embolism  of  the  right  iliac  artery, 
under  the  charge  of  Dr.  James  H.  Hutchinson,^  which  I  saw  with 
him,  it  may  recur  in  paroxysms  of  intense  severity,  and  be  referred 
to  the  foot,  though  this  be  already  in  a  condition  of  sphacelus.     Be- 

1  Amer.  Jouru.  Med.  Sci.,  Oct.  1863. 


DISEASES  OF  THE  BLOOD.  763 

sides  the  pain,  we  find  extreme  liypertesthesia  in  some  parts  of  the 
affected  hmb  ;  and  pricking  sensations,  formication,  and  loss  of  tactile 
sense,  followed  by  complete  anaesthesia,  in  others.  Then  painful 
spasms  of  the  muscles,  and  a  more  or  less  perfect  paralysis  of 
motion,  may  occur.  If  we  join  to  these  symptoms  an  absence  of 
pulsation  in  the  arteries  below  the  occlusion  until  the  collateral  cir- 
culation is  decidedly  established,  a  strong  beat  of  the  vessel  on  the 
cardiac  side  of  the  obstruction,  the  coldness  of  the  limb  below  this 
obstruction,  and  the  signs  of  defective  supply  of  blood,  we  have  a 
group  of  phenomena  which,  taken  in  connection  with  the  history  of 
the  case,  render  the  diagnosis  a  positive  one.  In  reviewing  the  his- 
tory the  state  of  the  heart  and  the  cardiac  symptoms  must  be  always 
carefully  examined  into ;  and  a  close  inquiry  often  shows  that  the 
sudden  manifestations  of  arterial  obstruction  were  preceded  by  an 
attack  of  palpitation  and  of  irregular  action  of  the  heart. 

A  change  in  the  physical  signs  of  the  diseased  organ,  as  of  its 
murmurs,  may  not  be  evident ;  but,  should  it  be  evident,  it  is  a  sign  of 
utmost  moment.  Indeed,  any  change  in  what  may  be  viewed  as  the 
centre  from  which  the  embolus  may  be  detached  is  of  great  signifi- 
cance. And  this  holds  good  quite  as  much  for  venous  as  for  arterial 
emboh.  Thus,  in  a  case  of  coagulum  in  a  vem,  a  sudden  disappearing 
of  swelling  and  cedema  of  the  affected  limb,  with  the  supervention  of 
signs  of  embarrassed  circulation  and  respiration,  would  at  once  tell 
what  had  taken  place. 

In  regard  also  to  the  diagnosis  of  embolism  we  must  always  bear 
in  mind  the  causes  that  are  likely  to  give  rise  to  it.  Several  of  the 
causes  of  arterial  emboHsm  have  been  already  mentioned ;  those  of 
venous  embolism  are  the  same  as  of  venous  thrombosis,  or,  to  speak 
more  explicitly,  the  breaking  up  of  the  clots  and  their  transportation 
may  occur  in  any  of  the  conditions  which  have  occasioned  them. 
Now,  these  conditions,  too,  will  produce  arterial  clots,  and  indeed 
some  are  more  apt  to  lead  to  coagulation  in  the  arteries  than  in  the 
veins.  Promment  among  them  are  a  narrowing  of  the  caliber  of  the 
vessel,  as  by  pressure  ;  dilatation  of  the  vessels  and  of  the  heart ;  fail- 
ure of  cardiac  power,  with  consequent  retardation  of  the  blood-stream, 
—a  state  which  is  more  likely  to  occasion  venous  than  arterial  throm-- 
bosis ;  a  breakage  in  the  continuit}-  of  the  vessel,  as  when  it  is  torn  or 
cut ;  changes  which  take  place  in  the  coats  of  the  vessels,  especially 
inflammatory  changes,  the  result  of  infective  disease  ;  and  contact  of 
the  blood  within  the  vessels  with  foreign  bodies.  Then  it  is  very 
likely  that  special  states  of  the  blood,  by  altering  the  cohesion  of  the 
globules,  or  disintegrating  them,  may  cause  the  clotting. 


764  MEDICAL   DIAGNOSIS. 

Another  cause  of  embolism  is  that  due  to  accumulations  of  jngment 
in  the  blood,  the  result  of  malarial  fever.  The  pigment  may  obstruct 
the  capillaries  in  the  brain  and  thus  occasion  capillary  apoplexies  ;  or 
be  driven  to  the  liver  and  there  produce  signs  of  disturbance  of  its 
circulation,  and  abscesses.  As  in  all  forms  of  capillary  embolism,  the 
symptoms  are  obscure :  the  suddenness  of  their  development,  gener- 
ally so  characteristic  of  the  other  forms  of  embolism,  is  wanting ;  and 
the  diagnosis,  as  throughout  in  capillary  embolia,  is  nothing  more  than 
a  matter  of  conjecture,  based  on  a  close  study  of  the  history  of  the 
case  and  the  general  phenomena,  including  the  microscopic  examina- 
tion of  the  blood.  Similar  symptoms  occurring  after  fractures  of  bone 
point  to  emboli  derived  from  the  marrow,  to  fat  embolism. 

Acute  endarteritis  may  be  the  cause  of  embolism  as  well  as  of 
pyeemia.  Air  in  the  blood  produces  great  disturbance  of  the  circula- 
tion, which  may  be  thought  to  be  due  to  embolism.  The  air  may  be 
the  result  of  decomposition,  and  get  into  the  venous  system  and 
thence  into  the  general  circulation.  Jurgensen  ^  has  reported  a-  case 
in  which  the  air  passed  into  the  circulation  through  the  splenic  vein. 
Irregular  contraction  of  the  heart,  pallor  of  the  face,  a  peculiar  systolic 
cardiac  murmur,  faint ness  and  the  signs  of  cerebral  anaemia,  and  slow 
breathing,  are  the  common  symptoms. 

In  conclusion,  the  subsequent  changes  of  the  thrombus  must  be 
adverted  to.  It  may  organize  and  be  converted  into  connective  tissue 
and  yield  an  impaired  passage  to  the  blood ;  and  perhaps  the  col- 
lateral circulation  may  be  freely  established ;  or,  what  is  not  so  favor- 
able a  result,  it  may  soften  and  undergo  a  granular  and  fatty  degen- 
eration. Further,  septic  or  purulent  thrombi,  as  they  soften,  may 
produce  septicaemia  or  pyaemia,  or  particles  of  the  thrombus  may  be 
wafted  into  capillaries  and  there  lay  the  foundation  of  abscesses.  It 
is  thus  that  in  a  case  of  thrombus  or  embolus  we  may  have  the  results 
of  a  secondary  pyaemia  to  deal  with. 

Scurvy. — This  disease  is  not  often  met  with  in  civil  practice ;  but 
it  is  one  familiar  to  the  military  and  the  naval  surgeon.  It  consists  in 
a  deterioration  of  the  blood,  produced  by  living  for  a  long  period  upon 
the  same  kind  of  food,  especially  upon  salted  meats,  without  the  requi- 
site supply  of  fresh  vegetables.  Another  cause  of  scurvy  is  the  want 
of  proper  assimilation  of  food,  as  in  prison  scurvy.^ 

'The  existence  of  scurvy  in  childhood  is  now  recognized  as  of  not 
infrequent   occurrence,  and  it   is   probably  frequently  mistaken    for 

1  Archivf.  klin.  Med.,  Bd.  xxxi.,  1882. 

^  See  Medical  Memoirs  of  the  U.  S.  Sanitary  Commission,  p.  278. 


DISEASES  OF  THE  BLOOD.  765 

rhachitis,  acute  rheumatism,  or  possibly  for  purpura.  Tlie  concurrence 
of  marked  anaemia  with  joint-swelHngs  in  a  bottle-fed  infant,  or  in 
older  children,  should  suggest  the  possibility  of  scurvy  being  present. 
Northrup  and  Crandall^  found,  in  over  sixty-three  per  cent,  of  the 
cases  of  infantile  scurvy  they  investigated,  that  the  diet  consisted  of 
proprietary  foods  and  condensed  milk.  The  evidence  also  indicates 
that  milk  sterilized  is  capable  of  causing  scurvy  when  used  as  an 
exclusive  diet. 

Babes,^  in  studying  three  cases  of  scurvy  bacteriologically,  found  a 
thin,  long,  wavy  bacillus,  prone  to  occur  in  clusters,  in  the  gums,  the 
lungs,  and  other  viscera.  There  were  also  streptococci  in  the  gums. 
The  blood  shows  nothing  characteristic.  The  red  corpuscles  are  only 
slightly  diminished,  the  haemoglobin  more  decidedly,  giving,  as  Coles  ^ 
says,  a  chlorotic  type  to  the  anjemia. 

Scurvy  is  usually  slow  in  its  development.  The  patient  becomes 
low-spirited,  easily  fatigued,  and  is  loath  to  exert  himself.  The  appe- 
tite is  impaired ;  there  is  a  craving  for  acids  and  for  vegetable  food ; 
the  tongue  is  flabby  ;  the  breath  fetid  ;  the  pulse  feeble  ;  the  skin  dry. 
The  bowels  are  usually  constipated  ;  but  a  tendency  to  diarrhoea  may 
exist,  and  indeed  generally  occurs  as  the  disease  advances.  Neuralgic 
pains,  referred  chiefly  to  the  lower  extremities,  to  the  bones,  and  to 
the  back  or  thorax,  are  common.  The  face  is  pale,  or  has  a  yellow- 
ish tinge ;  the  eyes  are  surrounded  by  a  dark  ring.  During  the 
progress  of  the  ailment,  or  in  severe  cases  almost  from  the  onset,  we 
And  swollen,  spongy  gums,  bleeding  on  the  slightest  touch ;  hurried 
breathing ;  a  rapid  pulse ;  weakened  eyesight,  sometimes  night-blind- 
ness ;  epistaxis  ;  painful  swelling  and  hardness  about  the  joints  of  the 
extremities  and  in  the  calves  of  the  legs  ;  and  purple  spots  and  bruise- 
like stains  on  the  skin.  Should  the  malady  remain  unchecked,  the 
symptoms  heighten  in  severity,  ulcers  form  which  have  a  fungoid  look 
and  a  great  tendency  to  bleed,  hemorrhages  take  place  from  internal 
organs,  old  sores  and  wounds  reopen,  well-knit  fractures  become  dis- 
united, there  is  a  constant  tendency  to  swoon,  and  the  patient  perishes 
miserably  exhausted,  and  with  his  blood  in  a  state  of  dissolution. 
Scurvy  may  be  the  cause  of  epidemics  of  pericarditis.^  In  some  cases 
death  takes  place  from  diarrhcea  or  dropsy,  which  may  be  suddenly 
developed.     Recovery  from  scurvy  is  slow. 

Purpura.— Scurvy  is  not  a  disease  difficult  to  recognize  ;  only  one 

^  Proceedings  of  New  York  Academy  of  Medicine,  Feb.  1894. 

*  Quoted  in  Sajous's  Annual,  vol.  i.,  1895. 

^  Diseases  of  the  Blood. 

■*  Von  Dusch,  Herzkruiikliritni. 


766  MEDICAL   DIAGNOSIS. 

affection  resembles  it  at  all  closely, — purpura.  In  this  disorder  also 
red  or  purple  spots  or  livid  blotches,  uninfluenced  by  pressure,  and 
passive  hemorrhages  from  the  mucous  membranes  happen.  But 
there  is  this  difference  between  the  two  complaints  ;  purpura  is  com- 
mon in  fruit  seasons,  and  often  attacks  persons  who  have  not  been  in 
any  way  deprived  of  vegetable  food.  The  gums  are  not  soft  and 
spongy  as  in  scurvy,  nor  do  we  find  the  same  weakness  of  mind  and 
body.  Then,  the  stain  of  the  skin  in  purpura  is  apt  to  be  more  gen- 
erally diffused,  and  the  purple  blotches  are  smaller,  or,  at  all  events, 
the  large  patches  of  discoloration  consist  clearly  of  an  aggregation  of 
very  many  small  spots.  Moreover,  the  disorder  is  not  controlled,  like 
scur^^'",  by  antiscorbutics,  such  as  fresh  vegetables  and  lemon-juice. 

From  a  clinical  point  of  view  we  find  several  forms  of  purpura. 
In  the  mildest,  the  purpurous  spots  are  apt  to  appear  only  on  the 
legs.  They  come  in  crops,  which  fade,  and  there  are  no  constitutional 
symptoms,  except  a  little  lassitude,  and  perhaps  aching  of  the  limbs 
and  pain  in  the  back.  In  the  graver  cases,  "  purpura  hemorrhagica," 
we  have,  in  addition  to  the  cutaneous  hemorrhage,  epistaxis,  haema- 
temesis,  hsematuria,  or  other  internal  hemorrhages,  and  extravasa- 
tions of  blood  may  happen  into  the  substance  of  the  muscles.  The 
amount  of  pain  attending  the  malady  is  very  different.  There  may 
be  none,  or  it  may  be  trifling ;  or  deep-seated  pains  in  the  cavities  of 
the  body,  or  extended  neuralgic  pains,  may  accompany  the  purpurous 
complaint ;  there  is  at  times  soreness  at  the  points  of  extravasation. 
In  some  instances  the  pains  are  chiefly  felt  in  and  around  the  joints, 
and  the  apparently  rheumatic  aches  subside  in  a  few  days,  and  spots 
of  extravasated  blood  become  visible.  This  "  purpura  rheumatica" 
is  usually  met  with  in  the  strong  and  healthy.  It  is,  indeed,  one  of 
the  peculiarities  of  any  kind  of  purpura,  that  it  may  come  on  in  the 
midst  of  seemingly  excellent  health ;  for  while  it  is  true  that  the  dis- 
order may  be  preceded  by  general  debihty,  or  occur  in  the  course  of 
disease  of  the  liver,  of  Bright's  disease,  or  as  a  sequel  to  the  exan- 
themata and  rheumatic  fever,  it  most  often  happens  where  we  should 
least  expect  it.  Its  production  as  the  result  of  a  sudden  shock,  such 
as  fright,  and  its  intermittent  character,  have  been  repeatedly  noticed. 
It  has  appeared  after  the  administration  of  quinine,  as  observed  by 
Vepau,^  by  Gauchet,^  and  by  Woodbury.'^ 

The  blood  shows  nothing  peculiar,  nothing  but  the  form  of  anaemia 
common  after  hemorrhages, — reduction  of  the  corpuscles  and  htemo- 

1  Gazette  Med.  de  Strasbourg,  1865. 
^  Bulletin  de  Therapeutique,  vol.  cl. 
^  Philadelphia  Melicnl  Times,  1886. 


DISEASES  OF  THE  BLOOD.  767 

globin,  slight  increase  of  the  white,  occasionahy  nucleated  red  cells. 
Purpura  is  clearly  not  merely  a  disease  of  the  blood ;  the  capillaries 
lose  their  retentiveness  and  allow  the  corpuscles  to  migrate.  The 
duration  of  the  malady  is  very  variable :  only  a  week  may  elapse,  or 
several  months  may  pass,  before  the  spots  disappear.  In  some  cases 
purpura  presents  an  acute  form.  It  is  ushered  in  by  a  chih,  and  by 
intense  pain  in  the  back  and  limbs,  but  is  unattended  with  fever  or 
severe  constitutional  disturbance.  The  purple  spots  usually  first  ap- 
pear on  the  legs,  and  are  wholly  uninfluenced  by  pressure.  They 
last  five  or  six  days,  or  somewhat  longer,  then  gradually  change  their 
color  and  fade.  Even  in  marked  hemorrhagic  cases,  the  mind  remains 
clear,  and  cerebral  or  spinal  symptoms  are  absent.  It  is  thus  that 
we  are  able  to  distinguish  severe  cases  of  acute  purpura,  which  may 
indeed  prove  fatal  in  forty-eight  hours,^  from  cerebro-spinal  menin- 
gitis. Some  of  these  acute  or  fulminating  cases  occur  in  young  chil- 
dren, and  it  is  a  question  whether  or  not  they  were  in  reality  subjects 
of  infantile  scurvy. 

The  distinction  between  hcemophilia  and  purpura  is  simple.  It  is 
true  that  in  the  former  the  bleeding  may  happen  into  the  skin,  or  from 
any  of  the  parts  from  which  it  may  take  place  in  purpura ;  but  the 
family  history,  the  congenital  proneness  to  frequent  hemorrhages 
from  the  slightest  cause,  their  danger  and  protraction,  the  functional 
disorder  of  the  heart,  followed  perhaps  even  by  cardiac  hypertrophy, 
the  attacks  of  rheumatoid  joint-inflammation,  especially  after  exposure 
to  cold  and  damp,  and  the  hemorrhagic  diathesis  exhilDited,  stamp 
haemophilia  with  distinctive  features. 

Microscopic  examination  of  the  blood  of  haemophilia  shows  nothing 
different  from  the  anaemia  found  in  scurvy  or  in  purpura.  Microcytes, 
and  reduction  of  haemoglobin  and  of  the  red  blood-corpuscles,  were 
found  by  Daland.-  Henry  has  directed  attention  to  the  wasting  of 
the  middle  muscular  tunic  of  the  arterioles.  Vasomotor  influences 
undoubtedly  play  their  part  in  bringing  about  an  attack.  This  is 
shown  by  the  flushing  of  the  face  which  so  often  precedes  it,  and 
also  by  the  fact  that  the  attack  may  follow  emotional  excitement. 
Leuheiiiia  may  be  accompanied  by  subcutaneous  extravasation  of 
blood,  but  it  cannot  be  mistaken,  for  either  haemophilia  or  purpura, 
if  an  examination  of  the  blood  be  made.  Haemophilia  is  almost  ex- 
clusivelv  restricted  to  tlie  male  sex. 


^  Harrisoii  Allen,  Amer.  Joum.  Med.  Sci.,  Jan.  1865. 
^  College  of  Physicians  of  Phil;i..  Jan.  9,  1894. 


CHAPTER   XL 

RHEUMATISM   AND    GOUT. 

Rheumatism  and  Gout  are  affections  having  a  strong  tendencj^  to 
change  their  seat,  and  are  dependent  upon  the  presence  in  tlie  hlood 
of  some  poisonous  material  wliich  probalDly  accumulates  there  in 
consequence  of  malassimilation.  The  rheumatic  poison,  concerning 
which  there  is  a  growing  but  as  yet  unproved  belief  that  it  is  a  mi- 
cro-organism, has  a  singular  predilection  for  the  fibrous,  serous,  and 
muscular  textures.  Hence  we  find  it  attacking  principally  the  joints, 
the  fasci£e,  the  endocardium  and  pericardium,  and  the  muscles  in 
various  parts  of  the  body.  According  to  its  main  forms,  it  is  some- 
times divided  into  articular  and  muscular ;  but  the  more  usual  division 
into  acute  and  chronic  is  simpler. 

Acute  Rheumatisni. — Here  the  poison  gives  rise  to  the  symp- 
toms of  an  acute,  active  disease,  and  attacks  especially  the  larger 
joints.  These  swell,  become  hot,  red,  tense,  tender,  and  the  seat  of 
pain,  aggravated  by  the  slightest  movement ;  an  effusion  also  takes 
place  into  the  surrounding  structures,  or  into  the  synovial  mem- 
branes of  the  joint  itself.  The  rheumatic  inflammation  may  either 
remain  confined  to  the  joints  first  affected  until  the  disease  is  over, 
or,  what  is  more  common,  it  shifts  from  joint  to  joint,  implicating 
most  of  the  large  ones  in  succession,  yet  often  invading  fresh  joints 
before  the  swelling  has  subsided  in  the  parts  first  attacked.  The 
articular  disorder  is  ushered  in  and  accompanied  by  high  fever,  soon 
attended  with  a  full,  bounding  pulse,  profuse,  sour  perspirations,  a 
white,  coated  tongue,  and  a  scanty,  turbid,  highly  acid  urine.  The 
fever  is  generally  in  proportion  to  the  number  of  joints  involved. 
Tonsillitis  is  not  an  unusual  early  symptom.  The  temperature  runs 
up  to  about  102°  or  103°  F.  very  soon  after  the  outbreak  of  the 
malady,  and  remains  steady,  with  slight  evening  exacerbations  and 
morning  remissions  when  the  joint-affection  is  yielding,  but  with 
renewed  rises  when  fresh  joints  are  being  implicated.  As  the  disease 
disappears,  the  fever  temperature  gradually  subsides. 

There  is  little  difficulty  in  recognizing  the  complaint.  The  pains 
in  the  joints,  their  tumefaction  and  tenderness,  the  shifting  character 

768 


JRHEUMATISM  AND  GOUT.  769 

of  the  disorder,  the  fever,  the  acid  sweats,  form  a  group  of  phenomena 
eminently  characteristic.  In  truth,  excluding  acute  gout,  the  only 
affections  at  all  likely  to  be  confounded  with  acute  articular  rheuma- 
tism are  pyaemia  and  glanders,  acute  synovitis,  and  milk-leg.  The 
diagnosis  of  the  former  has  been  discussed  in  connection  with  diseases 
of  the  blood ;  it  only  remains  to  point  out  the  marks  of  similitude  and 
contrast  between  acute  articular  rheumatism  and  the  other  maladies. 

Acute  synovitis  resulting  from  an  injury,  or  from  cold,  occasions,  like 
articular  rheumatism,  pain  and  heat  in  the  joint,  with  distention.  But 
the  disorder,  except,  perhaps,  if  it  happen  in  a  rheumatic  constitution, 
does  not  affect  more  than  one  joint ;  and,  as  there  is  scarcely  any,  or 
no,  effusion  into  the  surrounding  tissues,  the  outline  of  the  joint  can 
be  distinctly  discerned,  and  fluctuation  is  readily  detected.  Often, 
too,  the  accumulation  of  fluid  reaches  an  extent  far  greater  than  in 
rheumatic  inflammation ;  moreover,  the  febrile  and  constitutional 
derangement  is  not  so  severe  as  in  acute  rheumatism,  and  the  affec- 
tion has  no  tendency  to  change  its  seat.  Still,  acute  synovitis  may  be 
rheumatic. 

Milk-leg,  or  phlegmasia  alba  dolens,  occurs  usually  in  women  after 
delivery  or  as  a  sequel  of  continued  fevers,  sometimes  in  pneumo- 
nia, in  chlorosis,  or  in  tuberculosis.  Generally,  only  one  leg  swells, 
and  this  becomes  throughout,  or  only  around  the  calf,  preternaturally 
white,  firm,  hot,  and  shining.  The  tumefaction  is  uniform,  and  pain- 
ful, especially  so  when  touched.  It  does  hot  pit,  or  pits  but  slightly, 
upon  pressure,  except  at  the  lower  part.  There  is  tenderness  with 
a  sense  of  hardness  in  the  crural,  the  femoral,  or  the  internal  saphe- 
nous vein,  though  this  is  by  no  means  constant ;  yet  phlebitis  or 
periphlebitis  of  infective  origin,  whether  primary  or  secondary,  is 
apt  to  be  present,  and  to  be  associated  with  a  thrombus  in  the 
vein.  The  history  of  the  case  and  the  local  signs  are  very  different 
I'rom  acute  rheumatism.  Among  the  latter,  two  giving  rise  to  striking 
dissimilarity  may  be  mentioned :  the  almost  entire  loss  of  power  in 
the  affected  limb  in  phlegmasia  alba  dolens,  and,  the  much  higher 
temperature  it  shows  by  the  thermometer  than  the  other  members. 
An  increase^  of  general  temperature  corresponds  to  an  increase  of 
pain  and  swelling  in  the  limb,  and  of  constitutional  distress,^ 

Rheumatism  may  be  modified  in  its  manifestations  by  happening 
in  connection  with,  or  consequent  upon,  other  disorders.  For  in- 
stance, the  febrile  phenomena  may  be  of  an  adynamic  type  when 
the  disease  occurs  consecutively  to  typhoid  or  typhus  fever.     In  tlio 


^  Ellioit  Piicharclsoii,  Prunsylvaiiiii  H(is]iital  I'n'iiorfs,  vol.  ii. 

48 


770  MEDICAL  DIAGNOSIS. 

course  of  certain  infective  diseases,  such  as  scarlet  fever,  dysentery, 
cerebro-spinal  fever,  and  gonorrhcEa,  or  in  septic  states,  such  as  in 
pyaemia,  the  joints  swell,  and  there  may  be  symptoms  like  those  of 
rheumatism. 

In  gonorrhoeal  rheumatism  the  articular  pain  is  not  so  severe  or 
acute ;  the  integument  covering  the  affected  joint  is  apt  to  retain  its 
normal  color ;  there  may  be  but  one  joint — and  there  are  not  gener- 
ally many — implicated ;  the  inflammation  is  confined  to  the  synovial 
membrane,  and  a  copious  sero-flbrinous  exudation  occurs  ;  the  joint- 
affection,  which  is  found  chiefly  in  the  knees  or  the  sacro-iliac  or  the 
sterno-clavicular  joints,  shows  a  slight  tendency  to  shift,  and  resembles 
rather  an  acute  or  a  subacute  rheumatoid  arthritis  than  acute  rheuma- 
tism ;  the  eye,  too,  unlike  what  happens  in  ordinary  acute  rheumatic 
fever,  is  often  attacked.  There  is  but  little  fever,  no  copious  sweating, 
and  no  disturbance  of  the  heart,  though  there  may  be,  in  rare  in- 
stances, a  coexisting  gonorrhoeal  endocarditis  ;  often  there  has  been  a 
discharge  from  the  urethra,  which  diminishes  when  the  gonorrhoeal 
rheumatism  sets  in,  but  which  does  not  cease.  The  disorder  does  not 
come  on  early  in  a  case  of  gonorrhoea ;  and  the  joint-affection  appears 
really  to  be  of  pyajmic  origin.  It  disappears  only  very  slowly,  and  is 
uninfluenced  by  salicylic  acid.^  It  is  rare  in  women.  In  two  hun- 
dred and  fifty-two  cases  analyzed  by  Northrup  there  were  only 
twenty-two  women.  Gonorrhoeal  rheumatism  may  run  an  acute 
course.^ 

Purulent  effusions  into  joints  may  be  mistaken  for  acute  rheu- 
matism. The  history  of  the  case,  the  frequent  association  with  an 
infectious  or  septic  malady,  and  the  location  of  the  swelling,  distinguish 
these  jiycemic  joints.  They  are  also  met  with  in  puerperal  fever.  In 
acute  osteomyelitis  happening  in  the  long  bones  near  the  joints  there 
may  be  misleading  symptoms.  But  the  great  severity  of  the  pain,  the 
fact  that  the  epiphyses  rather  than  the  joints  are  affected,  and  the 
grave  constitutional  symptoms  prevent  error. 

The  traits  of  an  attack  of  acute  rheumatism  are  frequently  altered 
by  certain  complications  in  internal  organs  which  the  contaminated 
blood  occasions.  Prominent  among  them  are  the  cardiac  disorders, 
which  are  in  fact  so  common  that  they  may  be  looked  upon  as  form- 
ing part  of  the  rheumatic  manifestations.  Their  signs  we  investigated 
while  examining  endocarditis  and  pericarditis.  Certain  cardiac  phe- 
nomena, such  as  extreme  pain  without  evidence  of  valvular  affection, 


^  German  edition  of  this  work. 

■''  Davies-CoUey,  Guy's  Hospital  Reports,  1883. 


RHEUMATISM  AND  GOUT.  771 

pain  which  may  shoot  to  the  neck  and  shoulder  and  be  associated 
with  signs  of  great  irritability  of  the  heart  or  of  heart-failure,  have 
been  by  Peter  and  Letulle  ^  attributed  either  to  rheumatic  myocarditis, 
or  to  an  abnormal  excitement  of  the  cardiac  plexus,  of  rheumatic 
origin. 

Other  complications  are  inflammations  of  the  lung,  of  the  bron- 
chial tubes,  and  particularly  of  the  pleura ;  an  affection  of  the  kidney 
which  is  generally  a  parenchymatous  nephritis  with  some  albumin 
and  tube-casts,  but  which  may  be  due  to  pyaemic  or  embolic  infarc- 
tion,^ and — though  not  often — cerebro-spinal  disturbances,  exhibiting 
themselves  by  headache,  violent  delirium,  convulsions  and  coma,  and 
occurring  either  in  connection  with  peri-  or  endocarditis,  or  solely  in 
consequence  of  the  action  of  the  vitiated  blood  on  the  nervous 
centres,  or  of  uraemia,  or  of  multiple  capillary  embolism.  In  these 
cerebral  cases  the  temperature  is  apt  to  be  very  high,  to  reach  107° 
or  more,  but  the  association  is  not  invariable.  Indeed,  rheumatic 
delirium  is  far  from  always  of  the  same  nature.  It  may  develop 
itself  with  or  without  the  signs  of  cardiac  complaint.  It  may  come 
on  early  in  the  disorder  during  the  violence  of  the  fever ;  or  late, 
and  clearly  from  debility  and  impoverished  blood,  yielding  to  nour- 
ishment and  stimulants.  It  is  rarely  the  result  of  meningitis.  The 
delirium  which  attends  cerebral  rheumatism  may  be  marked  by  great 
talkativeness,  or,  on  the  other  hand,  the  patient  may  be  extremely 
taciturn.'^  Insanity  may  follow  the  brain  symptoms  of  acute  rheu- 
matism. In  some  instances,  whether  due  to  rheumatic  inflammation 
or  to  mere  disturbance  of  the  medulla  and  lower  half  of  the  pons, 
we  find  in  rheumatic  hyperpyrexia  nervous  symptoms  that  simulate 
multiple  sclerosis, — exaggerated  knee-jerks,  ankle-clonus,  scanning 
speech,  nystagmus,  and  tremor.  Foxwell''  has  reported  such  a  case 
in  which  the  temperature  reached  111°. 

The  occurrence  of  nodules  in  connection  with  rheumatism,  espe- 
cially among  children,  has  attracted  much  attention.  They  are  met 
with  chiefly  in  the  neighborhood  of  joints,  especially  of  the  elbow. 
These  fibrous  nodules  may  appear  at  once  in  any  form  of  rheu- 
matism, or  come  out  in  crops.  They  are  not  tender.  They  most 
often  occur  in  cases  of  rheumatic  endocarditis  or  pericarditis. 

^  Archives  Generales  de  Medecine,  June,  1880. 

^  Chomel,  Recherches  sur  les  Reins  dans  le  Rliumatisme,  Paris,  1868  ;  also 
Schmidt's  Jahrb.,  No.  2,  1871. 

^  Some  of  these  points  are  more  iully  detailed  in  my  jiaper  on  Cerebral  Rheu- 
matism published  in  the  Amer.  Journ.  Med.  Sci.,  Jan.  1875. 

*  Lancet,  May  188(). 


772  MEDICAL  DIAGNOSIS. 

In"  a  few  instances  of  rheumatism  we  find  acute  arteritis  arising, 
and  especially  inflammation  of  the  fibrous  structures  of  the  aorta. 
This  condition  may  be  suspected  should  we  observe  intense  general 
uneasiness  and  distress,  with  pain,  increased  pulsation,  a  distinct 
murmur  in  the  course  of  the  vessel,  and  tumultuous  action  of  the 
heart  without  there  being  obvious  signs  of  disease  of  that  organ 
present.     Still,  the  diagnosis  is  never  a  positive  one. 

Acute  rheumatism  rarely  ends  fatally ;  its  cardiac  consequences 
are  more  to  be  feared  than  the  acute  attack.  Cases  occur  not  infre- 
quently in  which  the  inflammation  in  the  joints  is  lingering,  and  in 
which  the  febrile  symptoms  are  not  intense.  These  cases  form  an 
intermediate  grade  between  acute  and  chronic  rheumatism,  and  are 
spoken  of  as  subacute.  The  disorder  is  more  apt  than  the  acute 
variety  to  affect  the  muscles  as  well  as  the  joints  ;  nay,  the  former 
may  be  alone  attacked.  It  may  be  witnessed  in  the  joints  of  one  ex- 
tremity, or  in  one  joint,  and  might  then  be  mistaken  for  synovitis. 
But  the  dissimilar  history  of  the  complaint  will  guard  against  error : 
no  accident  has  happened  to  account  for  the  swelling  of  the  joint,  and 
often  the  patient  will  tell  us  that  he  has  had  previously  an  attack  of 
rheumatism.  The  subacute  form  of  rheumatism  is  more  likely  to  be 
confounded  with  rheumatic  arthritis  :  we  shall  presently  refer  to  their 
distinction. 

Chronic  Rheumatisni. — This  may  be  either  a  sequel  of  the 
acute  disease,  or  the  disorder  may  from  the  onset  assume  a  lingering 
form,  the  constitutional  symptoms  being  slight.  The  affection  may 
show  itself  in  the  joints,  giving  rise  to  stiffness,  dull  aching,  pain  pro- 
duced by  motion,  but  without  heat  or  obvious  swelling,  tenderness, 
and  febrile  excitement,  or  marked  sweating ;  or  it  may  implicate  the 
muscles  in  various  parts  of  the  body,  occasioning  stiffness,  as  well  as 
pain  when  they  are  moved ;  or  it  may  attack  both  joints  and  muscles. 
In  any  case  the  occurrence  of  the  pain  furnishes  the  starting-point  in 
diagnosis  ;  and  we  must  ascertain  whether  it  be  augmented  by  motion, 
whether  it  be  more  or  less  shifting,  whether  it  be  not  combined  with 
stiffness  either  of  the  muscles  or  of  the  joints,  whether  it  be  influenced 
by  changes  of  temperature,  whether  it  be  not  neuralgic,  or  associated 
with  a  disturbance  of  some  viscus,  such  as  of  the  liver  or  the  kidneys, 
before  we  conclude  that  the  complahit  is  really  rheumatic. 

This  is  especially  necessary  in  the  most  common  form  of  chronic 
rheumatism, — muscular  rheumatism.  All  kinds  of  pains  in  the  mus- 
cles or  their  surroundings,  the  cause  of  which  is  not  at  once  apparent, 
are  apt  to  be  pronounced  rheumatic.  And  indeed  it  is  not  always 
easy  to  say  whether  they  are  or  are  not  of  that  character.     We  may 


RHEUMATISM  AND  GOUT.  773 

distinguish  them  from  neuralgia  by  the  pain  in  the  latter  being  ordi- 
narily confined  to  the  distribution  of  one  nerve  and  not  being  increased 
by  movement  or  by  pressure,  nor  is  it  so  steady,  or  attended  with 
soreness,  except  over  a  few  spots  in  the  course  of  the  affected  nerve, 
which  then,  indeed,  bespeaks  neuritis  rather  than  neuralgia. 

As  regards  the  pain  caused  by  organic  structural  disease^  we  can 
generally  discriminate  them  from  those  of  rheumatism  by  close  atten- 
tion to  the  history  of  the  case,  and  by  a  careful  exploration  of  the 
internal  organs.  Thus,  for  instance,  we  shall  find  pain  radiating  from 
the  right  hypochondrium  to  the  shoulder  to  be  dependent  upon 
hepatic  disease ;  or  pain  shooting  down  to  the  groin,  thigh,  and  testicle 
to  be  caused  by  a  disturbance  of  the  kidney ;  or  a  bearing  down  and 
an  aching  near  the  sacrum  to  be  probably  due  to  uterine  disorder, 
prostatic  disease,  or  anal  fissure. 

Muscular  rheumatism  may  affect  the  neck,  the  scalp,  the  muscles 
of  the  face,  and  the  parietes  of  the  chest  or  of  the  abdomen.  It  may 
be  not  only  chronic  in  any  of  these  situations,  but  also  acute  ;  or 
what  is  more  frequent,  when  it  occurs  with  fever  and  is  transient,  it 
is  a  sudden  acute  exacerbation  in  persons  who  are  rheumatic  and 
suffer  more  or  less  persistently  from  rheumatism,  though  perhaps  in 
a  different  part  of  the  body  from  ttie  one  in  which  the  acute  affection 
has  happened.  Muscular  rheumatism  has  been  noticed  in  an  epi- 
demic form,^ 

One  of  the  most  common  seats  of  muscular  rheumatism  is  in  the 
loins.  It  then  constitutes  the  disease  known  as  lumbago.  The  patient 
is  unable  to  stand  erect,  or,  after  being  seated,  to  assume  the  erect 
posture  without  suffering  much  pain,  and  finds  it  nearly  impossible 
to  stoop  forward,  on  account  of  the  pain  occasioned  when  the  mus- 
cles of  the  back  are  called  into  action.  Unless  the  attack  be  very 
severe  or  acute,  there  is  no  constitutional  disturbance ;  but  the  dis- 
order is  often  obstinate.  We  distinguish  it  from  pain  in  the  loins  due 
to  disease  of  the  kidneys,  chiefly  by  an  examination  of  the  urine  and 
by  the  way  in  which  movement  affects  the  rheumatic  pain ;  from 
lumbo-abdominal  neuralgia,  by  the  two  or  three  sore  spots  in  the 
course  of  the  affected  nerve  ;  from  rheumatism  of  the  vertebral  articu- 
lations, by  the  absence  of  tenderness  and  swelling  around  the  spi- 
nous processes  ;  from  lumbar  abscess,  by  the  want  of  local  bulging  or 
fulness,  of  fluctuation,  and  of  fever.  Then,  we  must  be  careful  not 
to  consider  as  lumbago  the  pain  in  the  back  caused  by  disease  of  the 
spine,  or  by  disorder  of  the  uterus,  or  by  the  passage  of  abnormal 

'  SchmiiU'sJiihrl..,  Xn.  12,  1872. 


774  MEDICAL   DIAGNOSIS. 

urinary  constituents,  such  as  oxalate  of  lime,  or  consequent  upon 
strains,  or  blows,  or  scurvy,  or  malaria,  or  ansemia,  or  a  general  or 
local  muscular  debility. 

Thus  there  are  many  causes  of  pain  in  the  loins,  and  where  the 
case  is  of  any  duration  or  of  any  doubt  we  must  be  careful  to  exclude 
these  causes  from  consideration  before  we  assume  the  disease  to  be 
really  rheumatism  of  the  muscles  and  fasciae  of  the  back.  This  cau- 
tion is  very  necessary  in  investigating  the  cases  of  "  weak  back"  so 
prevalent  among  soldiers,  which  are,  for  the  most  part,  due  to  strains 
or  injuries  that  have  perhaps  produced  a  weakness  of  the  muscles 
and  a  persistent  cutaneous .  hypersesthesia  ;  or  to  impoverished  blood, 
to  neuralgia,  to  scurvy ;  or  to  digestive  disorders  attended  with  the 
passage  from  the  kidneys  of  large  amounts  of  urates  or  of  oxalate  of 
lime. 

The  remarks  made  with  reference  to  lumbago  and  the  states 
which  simulate  it  are  also  applicable  to  pains  apparently  muscular 
affecting  other  portions  of  the  body.  We  may  have  pain  and  sore- 
ness of  the  muscles  developed  by  strain  or  overwork  and  attended 
both  with  muscular  and  with  cutaneous  hyperaesthesia, — a  condition 
very  different  from  rheumatism,  and  designated  myalgia.  This  sore- 
ness of  the  muscles  is  always  in  direct  proportion  to  their  debility, 
and  is  chiefly  caused  by  long-continued  exertion  beyond  the  power 
of  the  muscle,  or  by  an  ordinary  amount  of  action  when  the  muscle 
or  the  individual  himself  is  debilitated.  The  morbid  state  is  very 
marked  during  convalescence  from  scarlet  fever,  where  it  may  be 
looked  upon  as  due  to  over-exertion  of  the  weakened  muscles.  The 
soreness  of  the  muscle  is  commonly  accompanied  by  heightened  sen- 
sibility of  the  skin  over  it ;  and  this  coexisting  cutaneous  tenderness 
.  is  an  important  diagnostic  sign.  Myalgia  is  chiefly  found  in  the  mus- 
cles of  the  trunk,  and  is  rarely  general. 

Another  form  of  muscular  involvement  that  we  may  here  men- 
tion is  wry-neck,  or  torticollis.  This  depends  chiefly  upon  contraction 
of  the  sterno-cleido-mastoid  muscle  of  one  side,  and  occasions  an 
ungainly  appearance.  But  every  case  is  not  of  rheumatic  origin. 
The  disorder  may  be  spastic,  or  may  depend  upon  nervous  injury, 
and  when  chronic  may  lead  to  alteration  in  the  muscular  structure. 
The  therapeutic  test  is  with  injections  of  atropine,  hypodermically, 
which  are  generally  useful,  not  only  for  their  remedial  effect,  but  also 
because,  even  in  chronic  cases,  they  may  show  us,  by  the  difficulty  or 
impossibility  of  relaxing  the  muscle,  how  much  of  it  is  really  changed. 

There  are  forms  of  pain  in  muscles  and  tendons  that  are  often 
mistaken  for  muscular  rheumatism.     AchUlochpiia  is  one ;  the  slight 


RHEUMATISM  AND  GOUT.  775 

swelling  about  the  insertion  of  the  tendo  Achillis,  with  pain  on  stand- 
ing or  walking  but  without  much  tenderness,  marks  an  affection  that 
is  frequently  not  Rheumatic.  In  3Iorton's  disease  the  pain  in  the  meta- 
tarsal phalangeal  articulation  of  the  fourth  toe  is  due  to  lierve-com- 
pression.  It  is  a  form  of  neuralgia,  which  occurs  in  seizures,  yet  only 
when  the  foot  is  moved  as  in  walking ;  there  is  neither  heat  nor 
swelling.  The  muscular  pains  of  trichiniasis  may  be.  mistaken  for 
muscular  rheumatism.  But  the  marked  exhaustion,  the  signs  of 
gastro-intestinal  catarrh,  and  an  examination  of  the  blood  direct 
attention  to  the  real  cause. 

A  form  of  chronic  rheumatism  which  also  may  be  briefly  men- 
tioned is  that  affecting  chiefly  the  fibrous  membranes,  such  as  the 
periosteum.  This  becomes  thick,  and  tender  on  pressure ;  its  thick- 
ening may  be  even  perceptible  to  the  touch  as  well  as  to  the  eye. 
This  kind  of  rheumatism  happens  especially  in  those  who  have  syph- 
ilis ;  but  it  also  occurs  where  no  such  taint  exists.  The  pains  are 
generally  much  more  severe  at  night ;  and  this  is  sometimes  assumed 
to  be  a  proof  of  the  syphilitic  character  of  the  disease, — but  incor- 
rectly so  ;  for  many  varieties  of  chronic  rheumatism  are  aggravated 
by  the  warmth  of  bed.  Indeed,  the  only  really  diagnostic  signs  of 
syphilitic  rheumatism  are  the  obvious  evidences  of  constitutional 
syphilis,  or  the  history  of  the  infection.  Still,  to  cases  in  which  sev- 
eral nodes  exist,  and  in  which  the  pains  more  particularly  affect  the" 
long  and  flat  bones,  and  in  which  iodide  of  potassium  speedily  modifies 
the  pains,  we  shall  be  rarely  wrong  in  attributing  a  syphilitic  origin. 

Chronic  rheumatism  is  often  feigned,  especially  by  malingerers  in 
the  army  and  the  navy,  and  the  deception  may  be  difficult  of  detec- 
tion. They  pretend  to  be  scarcely  able  to  walk,  or  hobble  around 
with  a  cane,  and  complain  much  of  the  pain  and  stiffness  in  their 
joints.  Yet  there  is  not  the  least  sign  of  deformity  or  real  stiffness  ; 
the  pain  is  always  stated  to  be  the  same  ;  and  their 'general  health  is 
excellent.  Their  way  of  using  the  stick,  too,  is  characteristic :  they 
move  it  each  time  they  move  the  seemingly  crippled  leg,  but,  as  a 
rule,  not  immediately,  thus  not  employing  it  as  a  support.  Anaes- 
thetics are  of  great  value  in  enabling  us  to  decide  as  to  the  real 
amount  of  immovability  of  the  limb. 

Gout. — This  disease  may  be,  like  rheumatism,  either  acute  or 
chronic.  Instead  of  describing  its  phenomena,  I  shall  at  once  point 
out  the  marks  of  difference  between  the  two  kindred  maladies.  In 
gout,  the  small  joints  are  chiefly  or  alone  affected ;  in  rheumatism, 
the  large.  The  gouty  inflammation  is  accompanied  by  more  local 
pain  and  redness  than  the  rheumatic,  and  by  cedema,  enlargement  of 


776  MEDICAL  DIAGNOSIS. 

the  veins,  and  desquamation  of  the  cuticle,  and  implicates,  at  least  at 
first,  only  one  or  a  few  joints,  especially  the  joint  of  the  great  toe ; 
while  rheumatism  attacks  the  joints  of  the  upper  'as  well  as  of  the 
lower  extremities.  In  gout  there  is  a  tendency  to  disease  of  the  kid- 
neys, with  a  moderate  febrile  disturbance,  and  no  profuse  sweats  ; 
but  we  meet  rarely  with  a  cardiac  complication,  at  least  a  valve  affec- 
tion, as  constantly  happens  in  rheumatism.  Gout  is  more  decidedly 
hereditary  than  rheumatism  ;  its  early  attacks  are  apt  to  recur  with  a 
certain  amount  of  periodicity,  and  last  about  a  week, — therefore  a 
much  shorter  time  than  those  of  rheumatic  fever.  During  the  parox- 
ysm of  gout  the  urine  is  scanty,  and  both  before  the  attacks  and 
during  the  first  days  the  uric  acid  is  strikingly  diminished. 

Gout  occurs  generally  in  men  of  middle  age  who  live  high  or  who 
drink  large  quantities  of  malt  liquor,  or  in  their  descendants,  particu- 
larly those  who  lead  inactive  lives  ;  it  also  is  seen  in  those  whose  sys- 
tems have  been  impregnated  with  lead  ;  while  rheumatism  is  usually 
met  with  in  the  weak,  is  excited  by  cold  and  damp,  is  almost  as  com- 
mon in  females  as  in  males,  and  is  oftener  found  in  the  young  and 
before  middle  age.  Gout  is  frequently  combined  with  a  deposition 
of  chalk-stones  in  the  joints  ;  rheumatism  never.  Then,  as  shown  by 
Garrod,^  we  possess  means  of  diagnosis  in  the  examination  of  the 
blood.  Uric  acid  is  always  present  in  large  excess  in  gout,  and  absent 
in  rheumatism.  Nor  is  the  method  of  detecting  the  uric  acid  difficult, 
if  we  make  use  of  Garrod's  ingenious  plan.  It  consists  in  obtaining 
the  crystals  of  uric  acid,  crystallized  on  a  thread  placed  in  a  mixture 
of  the  serum  of  the  blood,  or  of  the  fluid  from  a  blister,  with  acetic 
acid,  in  the  proportion  of  six  minims  of  the  acid  to  each  fluidrachm  of 
the  serum.  The  mixture  of  the  serum  and  acid,  with  the  thread  in 
it,  is  allowed  to  stand  in  a  shallow  watch-glass  from  twenty-four 
to  forty-eight  hours,  protected  from  the  dust.  In  the  blood  of  gouty 
patients  there  is  often  a  slight  increase  of  the  leucocytes. 

The  remarks  just  made  apply  more  especially  to  the  distinction 
between  acute  gout  and  acute  rheumatism.  The  chronic  disorders 
are  more  difficult  to  separate.  Indeed,  unless  there  be  external 
deposits  or  chalk-stones,  their  discrimination  may  be  impossible.  In 
these  obscure  cases,  however,  the  history  and  an  examination  of  the 
blood  may  throw  considerable  light  on  the  diagnosis.  In  many  sub- 
jects, too,  the  exploration  of  the  external  ear  will  assist  us  in  arriving 
at  a  correct  diagnosis :  we  find  one  or  several  spots  of  subcutaneous 
deposit  of  urate  of  sodium  on  the  helix. 


Gout  and  Rheumatic  Gout,  2d  edit.,  Loudon,  1863. 


RHEUMATISM  AND  GOUT.  777 

Gouty  persons  are  subject  to  indigestion,  flatulency,  pains  and 
cramps,  or  palpitation  of  the  heart, — phenomena  due  to  the  gouty 
poison,  and  generally  ameliorated  by  a  fit  of  gout.  The  teeth  of 
those  of  gouty  diathesis  are  remarkably  Avell  enamelled,  enduring, 
and  free  from  decay  ;  but  there  is  great  proneness  for  tartar  to  col- 
lect upon  them.^  Violent  fits  of  sneezing  may  be  a  most  annoying 
symptom,^  and  so  are  deep-seated  pain  in  the  tongue  and  a  sense  of 
burning.^  In  chronic  gout  there  are  often  knotty  finger-joints  and 
tophaceous  deposits  in  fingers  and  toes.  Gouty  endarteritis  is  not 
uncommon  ;  and  the  frequent  association  of  contracted  kidney  with 
gout  is  universally  recognized.  Hay  fever,  or  asthmatic  seizures,  may 
be  symptomatic  of  the  gouty  diathesis  or  lithsemia. 

The  gouty  inflammation  of  the  joints  may  retrocede  during  an 
attack,  and  severe  epigastric  pain,  nausea,  vomiting,  flatulence  and 
acidity,  faintness  and  a  feeling  of  sinking,  and  a  quick,  feeble  pulse 
show  that  the  morbid  action  is  transferred  to  the  stomach ;  or  it  flies 
to  the  head,  and  apoplexy  or  maniacal  symptoms  occur ;  or  to  the 
heart,  and  there  is  violent  palpitation,  with  dyspnoea  and  intense 
anxiety ;  or  it  attacks  the  spinal  eord,  and  a  sense  of  constriction 
around  the  thorax  and  abdomen,  and  piercing  pains  in  the  limbs,  like 
those  of  locomotor  ataxia,  are  encountered,  and  the  spinal  dura 
mater  and  the  roots  of  the  spinal  nerves  are  found  to  be  incrusted 
with  uric  acid  and  urate  of  sodium.* 

Closely  connected  with  gout  is  lithcemia.  Indeed,  the  excessive 
formation  of  lithates  and  the  dyspeptic  symptoms  with  heart-burn 
and  eructations,  the  signs  of  functional  derangement  of  the  liver, 
the  vertigo,  the  mental  gloom  or  the  listlessness  and  indisposition 
to  exertion,  the  cramps  in  the  legs  and  muscular  twitchings,  the 
neuralgic  attacks,  the  restless  nights,  the  palpitations  of  the  heart 
and  its  irregular  beat,  are  in  many  but  the  precursors,  although,  it 
may  be,  the  long  precursors,  of  a  regular  outbreak  of  gout ;  while  in 
many  more  this  half-dyspeptic,  half-nervous  condition,  with  the  faulty 
assimilation,  the  imperfect  oxidation,  the  excessive  discharge  of  lith- 
ates at  times  and  their  disappearance  at  other  times,  will  go  on  for 
years  without  ever  developing  into  an  attack  of  gout.""'  Still,  in  time, 
the  same  local  lesions  may  follow  in  internal  organs ;  we  may  have 

^  Dyce  Duckworth,  Transact.  Odonlol.  Soc.  of  Great  Britain,  1883. 
■'  Schmidt's  Jahrbiicher,  No,  8,  1881. 
3  Dyce  Duckworth  on  Gout,  London,  1889,  p.  87. 
■*  Ollivier,  Archives  de  Physiologic,  1878. 

^  See  paper  on  Litliannia,  by  the  author,  Amer.  Journ.  Med.  Sci.,  Oct.  1881  ; 
and  University  Medical  Miitia/.ine,  May,  1894. 


778  MEDICAL   DIAGNOSIS. 

the  same  form  of  contracting  kidney,  arteriosclerosis,  and  the  heart- 
affection  with  hypertrophy,  and  tlie  accentuated  second  aortic  sound 
of  the  hthsemic  state.  Litliaemia  is  very  common  in  this  country,  and 
may  be  termed  American  gout. 

Lithaemia  sometimes  manifests  itself  in  attacks  of  pain  in  the 
stomach  and  boioels.  The  pain  is  associated  with  tenderness,  and  is 
most  common  when  the  stomach  is  empty.  Among  the  symptoms  of 
lithaemia  that  are  very  liable  to  be  mistaken  and  mistreated  are  disor- 
ders of  vision.  As  Risley  ^  has  stated,  lithaemia  is  both  a  primary  and 
a  modifying  factor  in  many  of  the  discomforts  and  more  serious  disor- 
ders of  the  eye.  It  stands  second  only  to  syphilis  in  the  frequency 
with  which  it  causes  iritis.  In  adults,  obstinate  conjunctivitis  and 
episcleritis  are  apt  to  own  lithsemia  as  a  cause,  and  it  often  gives  rise- 
to  pain  and  to  photophobia.  It  may  lead  to  ulceration  of  the  cornea 
and  errors  of  refraction  and  attendant  eye-strain  and  headache. 

Arthritis  Deformans. — Gout  is  rare  in  this  country.  But  the 
same  cannot  be  said  of  that  distressing  disorder  known  as  arthritis 
deformans,  or  rheumatie  gout,  which  is  neither  rheumatism  nor  gout, 
— though  not  uncommon  in  those  of  gouty  history, — but  a  distinct 
affection.  The  disorder  may  be  acute  or  chronic.  It  is  not  often  the 
former ;  many  of  the  acute  cases,  indeed,  being  rather  subacute  than 
acute.  Even  in  those  belonging  to  the  acute  form  there  is  little  febrile 
disturbance ;  and  though  we  observe  pain  and  aching  in  the  joints, 
and  some  discoloration,  we  find  less  redness  than  in  acute  rheuma- 
tism, and  certainly  the  tongue  less  furred,  much  less  profuse  perspira- 
tion, no  such  heavy  deposits  in  the  urine,  and  an  utter  freedom  from 
cardiac  complication.  The  acute  arthritic  disease  has  rather  inflam- 
mation of  the  pleura  and  of  the  eye  as  its  attendants,  and  is  often 
accompanied  by  a  sallow  skin,  yellowish  conjunctiva,  and  discolored, 
costive  stools.  It  implicates  the  large  and  small  joints  equally,  thus 
differing  from  gout,  and  causes  very  great  swelling,  due  to  an  effusion, 
not  around  the  joint,  but  into  its  capsule.  It  fastens  upon  several 
joints,  and,  though  it  may  pass  from  joint  to  joint,  it  shows  but  little 
migratory  tendency ;  the  joints  first  attacked  remain  the  seat  of  dis- 
ease. Unlike  gout,  it  is  apt  to  affect  the  smaller  joints  of  the  hands 
without  a  previous  affection  of  the  toes,  and  exhibits  no  periodic 
paroxysms  or  exacerbations.  Moreover,  an  acute  attack  is  of  very 
much  longer  duration.  Unlike  subacute  rheumatism,  it  does  not  affect 
the  muscles,  and  is,  both  in  the  suffering  at  the  time  and  in  its  ultimate 
results,  a  much  graver  malady. 

'  Proceedings  of  the  State  Medical  Society  of  Pennsylvania,  1895. 


RHEUMATISM  AND  GOUT.  779 

The  great  danger  in  deforming  arthritis  is  from  the  effects  of  the 
inflammation  on  the  joints.  The  clianges  there  produced  are  obvious 
in  the  chronic  form,  for  each  joint  attacked  is  apt  to  be  mucli  damaged. 
The  chronic  complaint  may  follow  the  acute,  or  it  may  begin  without 
any  febrile  symptoms,  with  pain  and  stiffness  in  the  joints.  These 
soon  become  much  distended  with  fluid,  which  is  gradually  absorbed, 
and  the  structure  of  the  joint  alters,  the  cartilages  become,  sooner  or 
later,  implicated,  and  gradually  waste,  and  chronic  changes  and  per- 
manent deformity  are  produced.  The  alterations  may  go  on  getting 
worse  and  worse  in  consequence  of  repeated  attacks,  until  complete 
immobility  ensues,  and,  the  joints  becoming  permanently  affected,  the 
ends  of  the  bones  are  dislocated  and  enlarged.  But  though  there  is 
much  swelling,  no  deposits  of  urate  of  sodium  are  found  in  the  joints. 
The  appearance  of  the  joints  seen  with  the  X-rays  is  very  character- 
istic. The  enlargement  and  irregularity  of  the  articulating  surfaces 
and  the  bony  outgrowths  at  the  margins  are  conclusive  evidence  of  the 
affection,  and  unlike  anything  perceived  in  either  rheumatism  or  gout. 
Occasionally,  especially  in  men,  the  disease  is  only  found  on  one  side 
of  the  body,  and  may  show  itself  only  in  a  large  joint,  as  in  the  hip 
or  the  shoulder,  or  affect  only  the  spinal  column,  producing  immo- 
bility. Among  its  peculiar,  though  less  constant  symptoms,  are  very 
rapid  pulse,  sweating,  and  pigmentation  of  the  skin,  like  freckles.  In 
one  of  the  forms  of  the  disease,  little  nodes  are  found,  especially  at 
the  sides  of  the  second  phalanx  of  the  fingers,  and  gradually  increase 
in  size.  These  "  Heberden  nodes"  in  time  become  associated  with 
eburnation  of  the  ends  of  the  bones. 

Charcot  has  pointed  out  that  in  j^'^ralysis  agitans,  in  addition  to 
rigidity  of  the  muscles,  deformities  of  the  fingers  result  resembling 
closely  those  of  chronic  articular  rheumatism.  But  the  likeness  to 
the  deformities  caused  by  rheumatic  gout  is  still  closer,  and  to  dis- 
tinguish them  we  must  take  into  account  the  whole  history  of  the- 
case,  the  tremor,  the  fixed  look,  the  peculiar  gait,  the  indistinct  speech, 
the  tremulous  handwriting,  the  sensation  of  excessive  heat.  More- 
over, the  disfigured  joints  are  not  stiff,  and  do  not  crack.  The  ar- 
thropathies of  locomotor  ataxia  may  be  mistaken  for  arthritis  defor- 
mans, but,  irrespective  of  the  history  and  of  the  characteristic  pains, 
the  absence  of  the  patellar  tendon  reflex  distinguishes  them.  All 
these  joint  affections  following  nervous  diseases,  and  sometimes  classed 
together  as  sjmrious  arthritis,  differ  from  joints  attacked  by  rheuma- 
tism or  by  deforming  arthritis  in  the  absence  of  marked  swelling  and 
of  pain,  except  on  forcible  movement ;  stiffness  is  the  prominent 
feature. 


780  MEDICAL   DIAGNOSIS. 

Deforming  arthritis  is  more  common  in  women  than  in  men ;  Kke 
rheumatism,  it  may  be  excited  by  cold  and  damp,  and  is  very  apt  to 
occur  in  the  weak  and  unhealthy.  It  generahy,  even  in  cases  that  re- 
cover, persists  for  months.  Nor  will  it  yield  to  the  remedies  usually 
administered  in  acute  rheumatism  ;  nor  to  colchicum  and  the  alkalies, 
so  beneficial  in  gout.  Its  causation  is  still  unsettled.  In  children  a 
form  of  arthritis  deformans  has  been  particularly  described  by  Still, 
in  which  with  the  general  enlargement  of  the  joints  there  is  swelling 
of  the  lymph-glands  and  of  the  spleen. 

I  shall  here  add  a  short  description  of  a  disease  of  nutrition  of 
dissimilar  character  to  those  described,  but  having  this  in  common, 
that  it  markedly  affects  the  organs  of  locomotion, — rickets. 

Rickets. — In  this  country  rickets  is  a  comparatively  rare  affection, 
certainly  rare  as  compared  with  its  prevalence  in  England,  in  Holland, 
in  Germany,  and  in  some  other  Continental  States.  It  is  a  constitu- 
tional disease  of  early  childhood  connected  with  impaired  nutrition, 
and  is  chiefly  characterized  by  increased  growth  of  the  epiphyses  and 
periosteum,  and  imperfect  ossification,  producing  softening  of  the 
bones  with  curvatures  and  distortions.  The  changes  are  most  mani- 
fest in  the  long  bones ;  and  the  amount  of  organic  matter  in  them  is 
more  than  doubled,  while  the  calcareous  salts  are  greatly  diminished. 
Besides  the  osseous  changes  there  is  evident  cachexia ;  and  the  liver 
and  spleen  become  enlarged  and  indurated  from  overgrowth  of  the 
glandular  elements  and  interstitial  development  of  fibroid  tissue.  A 
similar  process  may  also  happen  in  the  kidneys  and  in  lymphatic 
glands. 

Insufficient  and  improper  food  is  a  powerful  cause  of  rickets. 
The  malady  may  show  itself  as  late  as  the  seventh  or  eighth  year ; 
but  it  generally  sets  in  during  the  first  or  second  year  of  life.  When 
it  leads  to  death,  it  does  so  usually  by  gradual  exhaustion,  by  impair- 
ment of  the  digestive  functions,  by  thoracic  complications,  such  as 
extensive  bronchitis,  pleurisy,  or  collapse  of  the  lungs,  by  spasm  of 
the  glottis,  by  convulsions,  or  by  chronic  hydrocephalus.  As  a  marked 
disease  it  does  not  usually  last  longer  than  a  year,  though  the  results 
of  the  osseous  changes  may  long  persist,  and,  affecting  the  thorax  or 
the  pelvis,  prove  eventually  very  injurious. 

The  beginning  of  the  disease  is  generally  about  the  period  of 
dentition,  and  insidious.  The  child  makes  no  attempt  at  walking,  or 
ceases  to  walk  if  it  have  commenced.  It  is  languid,  irritable,  its  face 
pale,  its  tissues  flabby.  The  appetite  fails,  there  are  thirst  and  irreg- 
ularity of  the  bowels,  or  the  marked  signs  of  a  gastro-intestinal  catarrh. 
Restlessness  at  night,  a  disposition  to  throw  off  the  bedclothes,  pro- 


RHEUMATISM  AND  GOUT.  781 

fuse  perspiration  about  the  head,  neck,  and  chest,  while  the  rest  of 
the  body  is  hot  and  dry,  attend  an  irregular  febrile  condition  which 
soon  shows  itself;  while  fear  of  being  touched,  or  general  soreness 
and  tenderness  of  the  body  or  actual  pain,  bespeaks  the  local  process 
that  is  going  on  in  the  bones  and  their  covering.  The  changes  in  the 
bones  now  become  more  and  more  distinct.  The  joints  appear 
swollen,  especially  at  first  the  wrist-joints,  and,  when  these  are 
examined,  the  lower  extremities  of  the  radius  and  the  ulna  are  found 
to  be  enlarged  ;  similar  changes'  are  perceived  in  the  tibia  and  fibula, 
and  in  the  elbow.  There  is  tenderness  along  the  ribs,  and,  should  the 
affection  continue,  nodules  are  felt  at  the  junction  of  the  ribs  with 
their  cartilages  ;  the  sternum  protrudes,  a  pigeon-breast  results  ;  then 
the  limbs  show  contortions,  the  clavicles  are  bent,  the  spine  may  be 
curved,  the  pelvis  deformed.  The  head  is  large  and  square,  the  fore- 
head high,  the  anterior  fontanel  remains  unclosed,  the  sutures  are 
open  and  thickened  on  the  sides.  A  blowing  sound  is  frequently  to 
be  perceived  over  the  cranial  sutures.  Dentition  is  delayed,  or  the 
teeth  decay  and  fall  out.  The  urine  is  copious,  and  contains  lactic 
acid  and  an  excess  of  phosphates.  Convulsions,  laryngismus  stridulus, 
and  tetany  are  among  the  complications.  In  advanced  cases  the 
symptoms  of  cachexia  are  very  marked ;  the  flabby  muscles,  the  wan, 
aneemic  aspect,  the  large  abdomen  contrasting  with  the  small  face,  the 
enlarged  liver  and  spleen,  the  persistent  tenderness  over  the  bones, 
and  at  times  the  marked  fever,  give  sad  evidence  of  altered  nutrition 
and  of  suffering ;  yet  even  then  the  little  patient  may  recover,  though 
most  likely  with  part  of  the  osseous  system  irretrievably  damaged. 
Of  course  we  have  all  kinds  of  gradations  in  the  malady,  and  the 
general  symptoms  attending  the  morbid  process  may  be  slight,  just  as 
the  rickety  condition  of  the  bones  may  be  limited. 

The  diagnosis  will  have  been  made  apparent  from  the  description 
of  the  symptoms.  In  advanced  cases  there  can  be  no  doubt.  The 
changes  in  the  bones,  the  curvature,  the  distortions,  the  appearance 
of  the  patient,  the  evidences  of  cachexia,  clearly  stamp  the  malady. 
Earlier  in  the  disease  it  may  be  confounded  with  the  manifestations 
of  hereditary  syphilis.  But  this  affection  comes  on  even  sooner  than 
rickets,  almost  from  birth ;  there  are  other  signs  of  the  constitutional 
taint,  including  early  enlargement  of  the  spleen,  syphilitic  coryza,  and, 
at  a  later  period,  the  notched  teeth  ;  a  distinctive  history  may  perhaps 
be  obtained ;  and  the  enlarged  bones  not  infrequently  suppurate,  the 
swollen  epiphyses  become  detached,  and  osteophytes  form, — changes 
not  met  with  in  rickets. 

Mollities  ossium  produces  deformities  which  may  be  mistaken  for 


782  MEDICAL  DIA'GNOSIS. 

those  of  rickets.  But  the  softening  of  the  bone  is  the  result  of  its 
disease,  and  not  of  its  want  of  proper  ossification.  Tliere  is  consid- 
erable difficulty  in  locomotion,  and  the  bones  bend  or  break,  after 
having  been  affected  with  deep-seated  pains.  The  malady  lasts  for 
years,  and  is  not  one  of  childhood,  being  most  common  between  the 
ages  of  twenty-five  and  forty,  and  attacking  chiefly  women.  The 
pelvic  bones  are  often  implicated ;  it  is  doubtful  if  the  phosphates  in 
the  urine  are  increased,  but,  as  in  rickets,  the  urine  contains  lactic 
acid.  Yet  there  are  not  the  characteristic  signs  at  the  cranial  bones, 
the  open  fontanel  and  sutures,  nor  the  swelling  of  the  epiphyses, 
which  this  malady  so  strikingly  presents. 

There  are  cases  described  as  acute  rickets  which  are  a  combination 
of  rickets  and  scurvy}  They  are  most  common  in  infancy,  and  gen- 
erally present  the  spongy  gums  only  about  the  teeth  that  have  been 
cut.  They  sometimes  show,  in  addition  to  periosteal  hemorrhages,  a 
sudden  protrusion  of  one  eyeball.  In  the  early  stages  rickets  may  be 
mistaken  for  a(mte  or  subacute  rheumatism;  the  fever,  the  pain,  the 
sweats,  and  the  swelling  near  the  joints  mislead.  But  the  age,  the 
size  of  the  epiphyses,  the  absence  of  redness  of  the  joints  and  of 
heart-lesion,  the  "  beading"  of  the  ribs,  the  signs  of  beginning  cachexia, 
the  faulty  dentition,  and  the  pale  urine  full  of  phosphates,  tell  the  true 
meaning  of  the  symptoms.  Moreover,  the  apparent  joint-affection  is 
apt  to  show  itself  at  the  wrist-joints,  always  a  suspicious  circumstance 
in  delicate  young  children. 

Some  of  the  local  deformities  that  result  and  the  diseases  with 
which  they  may  be  confounded,  as  of  the  thorax  and  of  the  head, 
have  been  elsewhere  discussed.  Besides  the  alteration  of  the  skull 
in  chronic  hydrocephalus,  the  condition  described  by  Elsaesser  and 
others  as  cra.niotabes  may  be  mistaken  for  ordinary  rickets.  It  consists 
in  thinning  of  the  bones  of  the  cranium,  especially  of  the  occipital 
bone,  which  becomes  perforated,  allowing  the  membranes  of  the  brain 
to  come  in  contact  with  the  under  surface  of  the  scalp,  and  convul- 
sions may  be  induced  by  undue  pressure  over  the  points  of  perforation 
of  the  bone.  The  malady,  though  regarded  by  some  as  a  separate 
affection,  is  by  others,  by  Virchow  among  them,  looked  upon  as  due 
to  a  rhachitic  diathesis ;  we  certainly  often  find  evidences  of  this  in 
conjunction  with  the  peculiar  alteration  of  the  bones  of  the  skull. 

^  Barlow,  British  Medical  Journal,  1883,  i.  p.  1029,  and  "  Bradshaw  Lecture," 
ibid.,  1894  ;  also  St.  Louis  Courier  of  Medicine,  1883,  p.  453. 


CHAPTER    XII. 

FEVERS. 

Fever  is  either  a  symptom  of  some  strictly  local  malady  or  consti- 
tutes the  only  obvious  affection  present.  In  the  latter  case  the  disor- 
der is  called  essential  or  idiopathic  fever.  The  first  step,  therefore, 
when  fever  has  been  recognized,  is  to  ascertain  whether  it  is  sympto- 
matic or  idiopathic ;  whether,  in  other  words,  it  is  but  a  complement 
to  a  disease,  or,  as  far  as  can  be  ascertained,  the  disease  itself.  This 
is  not  generally  a  difficult  matter.  The  history  of  the  case,  the  course 
it  takes,  the  absence  or  presence  of  the  marked  peculiarities  of  seri- 
ous local  disturbances,  soon  determine  whether  we  are  dealing  with 
fever  as  a  symptom,  or  fever  as  a  disease.  Idiopathic  fevers,  with 
some  striking  exceptions,  are  characterized  by  the  want  of  definite 
and  invariable  anatomical  lesions.  That  in  all  changes  occur  in  parts 
of  the  nervous  system,  or  in  the  blood,  is  highly  probable.  But  there 
is  no  constant  injury  perceptible  in  the  organs  of  the  body:  some- 
times one,  sometimes  another,  suffers ;  sometimes  nearly  all ;  at 
times,  none,  certainly  none  in  an  obvious  manner.  When  we  contrast 
this  with  symptomatic  fever,  the  difference  is  striking.  The  visceral 
lesions,  then,  of  an  idiopathic  fever  are  not  the  starting-point  of  the 
fever,  but  rather  secondary  and  uncertain  complications.  In  idio- 
pathic fever,  the  fever  controls  the  lesions ;  in  symptomatic  fever,  the 
lesions  control  the  fever.  Idiopathic  fevers  are  mostly  infective  and 
of  bacillary  origin. 

Most  fevers  run  a  definite  course,  showing  a  strong  tendency  to  a 
spontaneous  termination  at  a  given  time.  At  their  beginning,  too, 
they  are  for  the  most  part  similar.  There  is  a  prodromic  state,  marked 
generally  by  unsound  sleep,  pain  in  the  back,  and  lassitude.  This  is 
followed  by  chills,  which  are  succeeded  by  heightened  temperature, 
arrested  secretions,  quick  pulse,  and  evident  fatigue  upon  the  least 
exertion.  The  fever  now  reaches  its  full  development  and  its  precise 
character  becomes  evident.  After  a  while  the  disturbance  declines, 
or  speedily  ceases  under  the  infiuence  of  critical  discharges,  and  a 
convalescence,  more  or  less  rapid,  sets  in.  An  unfavorable  termina- 
tion, on  the  other  hand,  may  take  place  at  any  period  after  the  system 
has  been  fairly  invaded. 

783 


784 


MEDICAL   DIAGNOSIS. 


The  marked  features  impressed  upon  the  fever  either  by  the  course 
it  runs,  or  by  the  specific  nature  of  tlie  symptoms,  go  to  form  wliat  is 
called  its  type^  and  may  be  made  the  basis  of  the  classification  of  all 
febrile  disorders.  But  as  opinions  have  been  and  are  still  diversified 
as  to  what  really  constitute  the  most  palpable  characteristics,  so  the 
classification  of  fevers  is  as  yet,  to  a  great  extent,  a  matter  of  specu- 
lation. In  the  following  table  no  attempt  is  made  at  an  exhaustive 
or  strictly  scientific  classification.  Some  disorders,  such  as  cholera 
and  epidemic  dysentery,  considered  by  many  eminent  pathologists  to 
belong  to  idiopathic  fevers,  have  no  place  assigned  to  them ;  pneu- 
monia, notwithstanding  its  undoubted  claims,  has  been  already,  for 
clinical  reasons,  elsewhere  considered.  Yet  from  a  diagnostic  point 
of  view  the  arrangement  adopted  is  convenient,  and  is  sufficiently 
accurate  to  be  free  from  grave  objections. 


Fevers. 


Continued  Fevers 


Periodical  Fevers 
(Malarial.) 


Eruptive  Fevers 


[  Simple  continued  fever. 

Catarrhal  fever,  or  influenza. 

Typhoid  fever. 

Typhus  fever. 

The  plague. 
<j    Cerebro-spinal  fever. 

Relapsing  fever. 

Yellow  fever. 

Dengue. 

Malta  fever. 

Glandular  fever. 

Intermittent  fever. 

Remittent  fever. 

Pernicious  fever. 

Scarlet  fever. 

Measles. 

Rubella. 

Smallpox. 

Varicella. 

Miliaria. 

Erysipelas. 


Continued  Fevers. 

All  continued  fevers  are  characterized  by  a  steady  progress  of  the 
febrile  movement,  without  either  decided  exacerbation  or  relaxation, 
the  rise  and  fall  observable  being  too  slight  to  modify  the  impression 
of  a  sustained  action. 

Simple  Continued  Fever. — Simple  fever,  or  febricula,  sets  in 
with  feelings  of  lassitude  and  chilliness  ;    to  these  succeed  hot  skin, 


FEVERS. 


<80 


excited  pulse,  thirst,  headache,  pain  in  the  Hmbs.  The  bowels  are 
generally  confined,  the  urine  high-colored.  The  lever  is  soon  at  its 
height ;  it  then  either  gradually  declines,  or  is  more  suddenly  relieved 
by  copious  perspiration  "  or  by  a  critical  discharge  from  the  bowels. 
Generally  it  runs  through  all  these  stages  in  a  few  days  ;  but  it  may 
be  protracted  for  upward  of  a  week  or  longer.  On  the  other  hand,  a 
day  may  witness  both  its  beginning  and  its  termination.  The  con- 
valescence is  almost  always  rapid. 

The  exciting  causes  of  this  form  of  fever  are  fatigue,  errors  in 
diet,  change  in  mode  of  life,  exposure  to  cold  and  damp,  or  to  the 
sun,  and  there  is  no  doubt  that  ptomaines  may  also  act  an  important 
part  in  its  production.  When  brought  on  by  mental  overwork  or 
by  anxiety  or  grief,  it  is  not  uncommonly  attended  with  increased 
sensibility  of  the  skin,  and  with  considerable  prostration,  simulating 
typhoid  fever,  but  differing  from  it  by  the  absence  of  epistaxis,  of  the 
peculiar  abdominal  symptoms,  and  of  the  eruption.  More  frequently 
the  fever  has  the  appearance  of  one  of  high  action.  At  times,  in- 
deed, it  is  so  intense,  and  the  vascular  system  is  so  wrought  up,  that 
the  distemper  assumes  what  is  called  an  inflammatory  type.  It  then 
exhibits  the  characteristics  of  the  fever  described  by  the  physicians  of 
the  last  century  as  synochus.  A  temperature  of  103°  or  upward, 
throbbing  of  the  temporal  arteries,  severe  headache,  and  delirium  are 
among  its  symptoms.  This  variety  of  the  fever  is  not  now  encoun- 
tered, save  in  tropical  latitudes,  and  is  a  form  of  the  so-called  thermic 
fever  of  Guiteras.  In  point  of  diagnosis,  it  is  most  apt  to  be  con- 
founded with  internal  inflammations,  especially  with  meningitis.  But 
there  is  not  the  vomiting,  nor  the  irregular  pulse  this  presents. 

In  addition  to  these  ordinary  forms  of  simple  continued  fever, 
which  are  of  short  duration,  there  is  a  form,  rare  it  is  true,  of  very 
long  duration,  and  in  which  the  fever  may  last  for  weeks,  without 
internal  complication  or  obvious  cause.  The  absence  of  eruption, 
of  enteric  symptoms,  and  the  negative  character  of  the  Widal  test 
distinguish  them  from  typhoid  fever.^ 

Catarrhal  Fever. — This  epidemic  malady,  Avhich  belongs  to  the 
idiopathic  fevers,  is  sometimes  described  as  a  mere  variety  of  bron- 
chitis, because  inflammation  of  the  bronchial  mucous  membrane  con- 
stitutes one  of  its  most  prominent  symptoms.  But  this  is  not  a  just 
view.  With  as  much  reason  might  typhoid  fever  be  omitted  from  the 
list  of  febrile  maladies  and  described  as  a  variety  of  enteritis. 


^  See  a  paper  of  mine  with  illustrative  cases  in  Amer.  Jduni.  Mod.  Sci..  June, 
1896  ;  also  Heubner,  Dentsches  Archiv  fiir  klinische  Medicin,  vol.  Ixiv.,  1899. 

4U 


786  MEDICAL   DIAGNOSIS. 

Catarrhal  fever,  or  influenza,  is  essentially  an  epidemic  disease, 
the  history  of  which  is  not  confined  to  any  particular  time  or  to  any 
particular  nation.  Its  cause  is  believed  to  be  a  slender  bacillus  found 
in  the  expectoration  and  nasal  secretion.^  But  its  bacillary  origin, 
though  very  probable,  has  not  been  demonstrated  beyond  question. 
Each  epidemic  does  not  furnish  precisely  the  same  train  of  symptoms  ; 
but  they  all  agree  in  this  :  the  disorder  sets  in  suddenly  and  attacks 
pre-eminently  the  mucous  membranes.  Generally  it  is  the  mucous 
membrane  of  the  nose,  eyes,  and  bronchial  tubes  that  suffers  most, 
and  we  find  the  signs  of  coryza  and  of  bronchial  inflammation, — a 
watery  eye,  sneezing,  uneasiness  about  the  throat,  and  a  tormenting 
cough.  But  associated  with  these  are  great  depression  of  spirits  and 
usually  an  extraordinary  amount  of  lassitude  and  impairment  of 
strength, — much  more  than  the  cold  in  the  head,  or  the  laryngitis,  or 
the  bronchitis,  will  account  for.  The  skin  is  hot,  at  times  covered 
with  perspiration  ;  the  thermometric  record  is  peculiar  only  in  its  ex- 
treme irregularity.  The  temperature  generally  ranges  between  100° 
and  102°,  or  starts  up  suddenly  to  104°  or  105°,  and  in  less  than  a 
day  subsides  almost  to  normal ;  the  pulse  is  of  moderate  volume,  the 
tongue  coated ;  the  patient  complains  of  debility,  of  headache,  of 
aching  pains  in  his  back  and  limbs,  and  of  constriction  at  the  lower 
part  of  the  chest.  Often  there  is  some  dyspncea,  as  well  as  epistaxis, 
hypersesthesia,  especially  of  the  neck  and  head,  and  disturbance  of 
the  alimentary  tract,  evinced  by  loss  of  appetite,  nausea,  and  vomit- 
ing, or  by  diarrhoea.  Commonly  after  three  or  four  days  these  symp- 
toms begin  to  subside,  the  cough  and  debility  outlasting  the  other 
morbid  signs.  The  cough  is  often  dry  and  harassing,  and  chiefly 
laryngeal. 

But  all  epidemics  do  not  run  precisely  this  course.  In  some,  the 
prostration  is  not  so  evident,  and  the  febrile  signs  are  more  active  and 
of  an  inflammatory  type;  in  others,  the  pain  and  soreness  in  the 
limbs  and  in  the  joints  are  the  most  prominent  symptoms ;  or  we 
may  find  hemicrania,  or  torpor  and  delirium,  or  parotitis  with  saliva- 
tion, or  otitis,  or  epistaxis,  or  catarrhal  jaundice,  or  bronchitis  of  the 
finer  tubes,  or  pneumonia,  or  tendency  to  heart-failure,  or  meningitis, 
basilar  or  spinal,  and  irregular  rashes,  as  complications.  Further,  as 
complications  or  sequelae  of  influenza  have  been  observed  various 
psychoses  and  neuroses,' or  neuritis,  local  or  multiple,  bulbar  palsy, 
acute  ascending  paralysis,  hemiplegia,  diabetes,  vascular  occlusion, 
gangrene,  angina  pectoris,  inflammation  of  the  lymphatic  glands  and 

^  Pfeiffer,  Zeitschrift  fiir  Hygiene  und  Infektionskrankheiteu,  March  3,  1893. 


FEVERS.  787 

of  the  antrum,  acute  nephritis,  and  painful  and  inflammatory  affec- 
tions of  tendons,  fasciae,  joints,  periosteum,  and  bones.  The  disease 
also  brings  out  a  latent  syphilitic  taint/  ' 

The  lung  comphcation  of  influenza  is  striking.  It  is  mostly  an 
intense  congestion,  with  bronchitis,  here  and  there  with  spots  of  con- 
solidation, a  broncho-pneumonia.  True  lobar  pneumonia  is  much 
rarer.  The  lung  affection  may  be  of  long  duration,  showing  the 
record  of  a  fever  with  marked  rises  and  remissions.  After  declining, 
the  temperature  may  become  subnormal  and  remain  so  with  occa- 
sional exacerbations  for  a  long  time,  as  seen  in  the  accompanying 
chart  of  a  case  in  my  ward  at  the  Pennsylvania  Hospital." 

Influenza  is  not  ordinarily  in  itself  a  fatal  disease.  It  is  only  so  in 
the  very  young  or  the  very  old.  It  is  also  a  grave  malady  in  persons 
with  weak  hearts.  A  source  of  danger  is  the  indurated  lung  it  may 
leave  behind  becoming  the  seat  of  tuberculosis. 

Catarrhal  fever  is  easily  discriminated  from  other  maladies.  Its 
peculiar  Epidemic  character  and  the  prostration  prevent  us  from  mis- 
taking it  for  an  ordinary  cold  or  bronchitis.  Occasionally  the  attend- 
ing debility  makes  it  look  like  the  onset  of  a  long-continued  fever. 
But  brain-symptoms  are  present  only  in  rare  instances  in  influenza ; 
and,  on  the  other  hand,  decided  catarrhal  symptoms  are  not  common 
in  typhoid  and  typhus  fevers.  Before  long,  too,  the  eruption  of  these 
diseases  clears  up  whatever  doubt  may  have  existed ;  rashes  of  any 
kind  are  extremely  rare  in  influenza,  and  are  of  irregular  type  when 
they  happen.  At  times  there  is  a  long-continued  fever  in  influenza 
like  that  of  typhoid  fever,  but  the  Widal  reaction  of  this  is  lacking. 

Catarrhal  fever  may  be  mistaken  for  hay-fever.  But  the  local 
symptoms  of  irritation  of  the  nostrils,  the  watery  eyes,  and  the  red- 
dened conjunctivas  are  very  striking,  and  the  febrile  movement  is  gen- 
erally less  than  in  catarrhal  fever.  Moreover,  there  are  asthmatic 
symptoms  in  hay-fever  or  hay-asthma  in  a  certain  proportion  of 
cases  ;  and  the  history  of  the  case,  the  manner  in  which  it  comes  on 
as  a  rose-cold  in  the  latter  part  of  May  or  early  in  June,  or  as  autum- 
nal catarrh  after  the  middle  of  August ;  the  hereditary  idiosyncrasy  so 
often  seen  ;  the  persistence  of  the  attack  while  exposed  to  the  peculiar 
vegetable  emanations  that  give  rise  to  it ;  its  almost  abrupt  cessation 
on;;removal  to  certain  localities,— make  up  a  set  of  features  which  are 
very  distinctive. 


'  Howard,  Laiuel,  July,  1899. 

^  For  a  full  description  of  the  \\i\v^  complications  of  influenza,  see  my  pajjer  on 
the  subject  in  the  "International  Clinics,"  Vol.  I.,  Second  Series. 


788 


MEDICAL  DIAGNOSIS. 


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FEVERS.  789 

When  influenza  is  prevailing  on  a  large  scale,  it  is  often  found 
masked  by  other  diseases,  and  it  may  be  difficult  then  to  separate  its 
manifestations  from  those  of  the  malady  it  accompanies.  Otlier  pecu- 
liarities of  influenza  are  the  long  time  it  takes  tlie  patient  to  regain 
his  strength,  and  the  annoying  sweats  that  attend  convalescence. 
This  was  striking  in  the  epidemic  of  the  early  winter  months  of  1890 ; 
as  was  also  the  tendency  to  repeated  attacks,  to  irregular  heart  action, 
and  to  alterations  of  cutaneous  sensibility. 

Typhoid  Fever. — In  this  country  and  on  the  continent  of  Europe 
a  form  of  continued  fever  prevails,  especially  among  young  adults, 
that  is  marked  by  great  prostration  and  disturbance  of  the  nervous 
system,  and  by  constant  anatomical  lesions.  To  this  disease  tlie 
designations  of  typhoid  fever,  enteric  fever,  and  abdominal  typhus 
have  been  applied. 

The  distemper  may  set  in  suddenly,  but  more  generally  it  has  an 
insidious  beginning.  For  some  days  preceding  the  access  of  the  fever 
the  patient  feels  weak.  He  is  without  animation,  complains  of  sore- 
ness and  fatigue,  of  dull  pain  in  the  head,  of  loss  of  appetite.  His 
sleep  is  unsound ;  all  exertion  is  wearisome.  A  fever  now  appears, 
preceded  mostly  by  a  chill,  or  by  chilly  sensations,  which  alternate 
with  flushes  of  heat.  The  muscular  prostration  accompanying  the 
febrile  movement  becomes  so  great  that  the  patient  is  obliged  to 
keep  his  bed.  His  appetite  is  entirely  gone,  the  tongue  is  coated,  the 
bowels  are  loose,  the  abdomen  is  somewhat  swollen  and  tender  to 
the  touch. 

The  malady  has  now  completed  its  first  week.  It  enters  on  the 
second  week  with  fever  unabated,  and  with  the  signs  of  disturbance 
of  the  alimentary  tract  and  of  the  nervous  system  more  and  more 
unmistakable.  There  is  sometimes  nausea  or  epigastric  distress,  often 
pain  in  the  right  iliac  fossa,  increased  by  pressure  and  tympanites. 
On  close  inspection,  a  few  reddish  spots,  resembling  flea-bites,  are 
found  on  its  surface.  The  tongue  dries  and  becomes  reddish  or 
brownish  ;  it  is  often  glazed  and  covered  with  a  light  coat ;  sometimes 
it  has  deep  fissures ;  very  frequently  I  have  noticed  at  the  tip  a  wedge 
of  brownish  or  reddish  surface  free  from  coat,  but  which  begins  to  be 
covered  over  as  the  disease  declines ;  the  gums  and  teeth  are  lined 
with  dark  crusts.  The  mind  is  dull  and  wandering ;  cough  and  great 
restlessness  exist ;  the  debility  is  extreme. 

The  disease  now  begins  to  draw  to  its  close.  It  has  reached  the 
third  week,  and  a  change,  for  better  or  for  worse,  may  be  looked  for. 
Slowly  recovery  sets  in,  marked  by  a  brightening  of  the  countenance 
and  by  a  gradual  increase  in  consciousness  and  strength  ;  or  deepen- 


790  MEDICAL  DIAGNOSIS. 

ing  insensibility,  jerking  of  the  tendons,  feeble  pulse,  and  cold,  clammy 
sweats  indicate  that  dissolution  is  fast  approaching. 

Thus,  in  one  way  or  the  other,  the  fever  itself  is  apt  to  terminate 
by  the  beginning  or,  more  generally,  by  the  middle  of  the  fourth 
week.  Yet  such  is  not  always  the  case.  Death  may  take  place  at  an 
earlier  period ;  or,  on  the  other  hand,  the  malady,  by  troublesome 
complications,  may  be  lengthened  beyond  the  second  month.  Under 
any  circumstances,  convalescence  is  protracted.  The  nervous  system 
rallies  but  gradually  from  the  shock  it  has  received. 

Among  the  symptoms  enumerated,  some  tend  clearly  to  charac- 
terize the  disease.  And,  first,  of  the  more  purely  febrile  symptoms. 
The  skin  during  the  fever  is  mostly  dry.  But  there  may  be  an  acid 
perspiration,  very  manifest  during  the  whole  course  of  the  disease, 
and  also  encountered  long  after  convalescence  has  feet  in.  The  pulse 
is  accelerated,  mostly  about  120,  and  is  rapid  even  after  the  fever  has 
left,  though  in  convalescence  it  may  be  much  slower  than  normal ;  it 
is  very  compressible,  and,  intercurrent  acute  inflammations  notwith- 
standing, it  seldom  loses  its  compressibility,  A  jerking,  irregular 
beat,  or  very  great  rapidity,  a  running  pulse,  is  an  unfavorable  sign. 
Dicrotism  of  the  pulse  is  not  unusual.  Associated  with  the  dimin- 
ished strength  of  the  pulse  is  a  decided  faintness  of  the  first  sound  of 
the  heart. 

The  temperature  is  peculiar ;  in  the  first  five  or  six  days  of  the 
disease  it  pursues  an  ascending  line ;  that  is  to  say,  starting  at 
the  normal  98.6°  F.,  there  is  a  daily  evening  rise  of  about  2°,  with 
a  morning  remission  of  about  1°.  From  the  fifth  or  the  sixth  day 
to  the  twelfth  or  a  little  later, — roughly  speaking,  we  may  say  from 
the  end  of  the  first  week  to  the  end  of  the  second,^he  fever  is 
continuous,  with  a  morning  remission  rarely  exceeding  1°.  From 
that  time  on,  let  us  say  from  the  twelfth  day,  although  the  evening 
temperature  may  remain  for  a  day  or  two  quite  or  nearly  as  high, 
there  is  an  abatement  of  from  1°  to  2°  in  the  morning.  These 
changes  between  morning  and  evening  become  very  evident  at  the 
end  of  the  week,  and  are  still  more  evident  in  the  third  week,  when 
the  morning  and  evening  temperatures  may  vary  as  much  as  from  4° 
to  6°.  During  this  week,  too,  the  evening  temperature  gradually  de- 
creases ;  but  in  severe  cases  it  remains  high,  and  there  are  no  decided 
remissions  either  in  the  second  or  the  third  week.  The  morning 
temperature  is  high,  104°  or  more,  and  there  may  be  still  greater  heat 
of  skin  in  the  evening,  or  else  it  differs  but  little  from  that  of  the 
morning.  One  hundred  and  six  degrees  is  a  high  temperature,  but  I 
have  known  it  107.5°,  yet  the  patient  recover.     The  peripheral  tem- 


FEVERS. 


791 


peratnre,  as  measured,  for  instance,  in  the  palm  of  the  hand,  becomes 
during  the  fever  as  high  as  the  axillary  temperature,  but  their  equali- 


HIIIIUIIIIIIIIHinillllllllllllllllllllillBss^llllllllBIUIIIIIIDl 


1131 


zation  ceases  prior  to  defervescence.'     in  exceptional   instances,  the 
temperature  may  be  normal   throughout;-  in  still  rarer  instances  it 


'  Couty,  Archives  de  Physiologie,  No.  2,  1880. 

^  Vallin,  Arch.  Gen.  de  Med.,  Nov.  1873  ;  Fiulayson.  Aincriciui  Journal  of  tlie 
Medical  Sciences,  March,  1891,  p.  225  ;  Wendland,  Deutsche  Medicinische  Wochen- 
schrift,  Aug.  29,  1892;  Dreschleld.    Pi'acfifioner,    No.   298,  vol.    1..    p.    272:   Fisk, 


792  MEDICAL   DIAGNOSIS. 

is  subnormal.^  I  have  never  seen  a  case  of  either  kind.  Occasionally 
the  curve  may  resemble  that  of  intermittent  fever.-  Again,  the  fever 
may  terminate  by  crisis  at  the  end  of  the  third  or  in  the  fourth  week. 
This  I  have  met  with  more  than  once. 

The  urine  is  acid,  high-colored,  scanty, — the  urine  of  fever. 
Ehrlich  has  stated  that  the  urine  of  typhoid  fever  gives  a  special  re- 
action,— the  diazo  reaction.  This  test  consists  in  taking  forty  parts  of 
a  saturated  solution  of  sulphanilic  acid  in  hydrochloric  acid,  one  to 
twenty,  and  one  part  of  a.  one-half  per  cent,  solution  of  sodium 
nitrite,  and  adding  them  to  an  equal  bulk  of  urine  rendered  alkaline 
by  strong  ammonia.  Normal  urine  is  colored  brownish  by  the  test 
liquid,  typhoid-fever  urine  pink  or  ruby,  with  slight  frothing.  The 
reaction  has  not  been  found  in  all  cases  of  typhoid  fever,  and  has 
been  obtained  in  a  variety  of  other  morbid  conditions,  such  as  tuber- 
culosis, typhus  fever,  measles,  scarlatina,  enteritis,  malaria,  pneu- 
monia, meningitis,  septicsemia,  uraemia.  The  toxicity  of  the  urine  is 
greatly  increased  in  typhoid  fever.  Robin  ^  regards  the  urine  as 
characteristic  even  from  the  onset ;  the  chief  characteristics  being  a 
peculiar  odor,  constant  presence  of  albumin  in  moderate  amount, 
absence  of  urohsematin,  presence  of  indican,  increase  of  uric  acid, 
marked  diminution  of  the  earthy  phosphates.  As  regards  the  albu- 
min, I  do  not  think  it  constant,  and  it  is  not  in  large  amounts.  It  is 
most  marked  in  severe  cases  and  those  with  high  temperature,  and  co- 
exists with  a  few  tube-casts.  In  the  so-called  renal  type  of  typhoid, 
in  which  an  acute  nephritis  for  the  most  part  happens,  we  also  find 
red  corpuscles,  free  granular  epithelium,  and  casts  of  various  kinds, 
though  not  oily  ;  there  is  considerable  albumin,  and  often  at  the  onset 
a  scanty  bloody  urine.  The  kidney  involvement  may  manifest  itself 
from  the  start,  and  persist  throughout.  In  very  rare  instances  of 
typhoid  fever  there  is  marked  haematuria. 

Among  the  abdominal  symptoms,  diarrhjea  is  prominent.  It  is 
mostly  present,  except  when  the  disease  is  unusually  mild,  though  its 
prevalence  varies  in  different  epidemics.  Generally  it  is  a  very  early 
symptom  ;  at  times  it  is  even  seen  among  the  prodromes.  The  clue 
to  its  cause  is  found  in  the  state  of  the  intestinal  glands,  in  the  en- 
largement and  ulceration  of  the  glands  of  Peyer  and  of  the  solitary 


Medical  News,  Nov.  3,  1894,  p.  479  ;  MacDougall,  Lancet,  April  15.  1893  ;  Mem- 
phis Lancet,  July,  1898. 

1  Raimondi.  Gazette  de?  Hopitaux.  1894,  No.  109  ;  Centrall)latt  fiir  Innere 
Medicin,  1895,  No.  G,  p.  152. 

-  MacDougall,  Lancet,  April  15,  1893. 

3  Bulletin  Med.,  No.  87,  1897. 


FEVERS. 


793 


glands,  with  the  tumefaction  of  the  mesenteric  glands.  And  in  these 
morbid  alterations  we  find  an  explanation  not  only  of  the  occur- 
rence of  the  diarrhoea,  but  also  of  its  frequency.  The  stools  are  thin, 
of  a  yellow  or  dark-brown  color,  and  of  offensive  smell.  When  the 
affection  is  at  its  height,  from  three  to  four  evacuations  occur  during 
the  twenty-four  hours ;  but  the  passages  may  become  much  more 
numerous,  and  with  their  number  the  danger  rises.  If  they  take 
place  without  the  knowledge  of  the  patient,  his  situation  is  precari- 
ous.    Sometimes  the  stools  contain  blood.      Should  this  be  present 

Fig.  76. 


Eberth  typhoid-fever  bacillus,  from  a  potato  culture.    The  broad  ones  are  really  two  bacilli  lying- 
in  juxtaposition.    Zeiss  -j'j,  homo,  im.,  Go.  5. 

in  considerable  quantity,  it  is  a  very  unfavorable  circumstance.  Yet 
intestinal  hemorrhage  is  by  no  means  necessarily  fatal.  In  rare  in- 
stances there  is  hrematemesis,  in  others  haemoptysis,  and  this  in  the 
absence  of  any  pulmonary  lesion.^ 

The  bacillus  giving  rise  to  typhoid  fever  is  the  bacillus  typhosus 
described  by  Eberth  and  by  Gaffky  (Fig.  76).  The  bacillus  is  chiefly 
found  in  the  intestinal  lesions  and  in  the  stools.  But  it  is  very  gen- 
erally diffused,  being  met  with  in  the  gall-bladder,  in  the  bone- 
marrow,  in  the  blood,  in  the  coats  of  vessels,  and  in  the  urine  even 
in  cases  in  which  there  are  no  renal  symptoms.     It  is  a  rather  plump 


1  Dickinson,  Lancet,  Feb.  17.  1894,  p.  421. 


794  MEDICAL  DIAGNOSIS. 

organism  from  two  to  three  [x  long,  with  rounded  ends,  actively 
motile,  and  staining  with  the  ordinary  aniline  colors.  It  is  very  sensi- 
tive to  high  temperatures,  and  does  not  form  spores. 

Unlike  the  colon  bacillus,  the  typhoid  bacillus  does  not  cause  fer- 
mentation in  glucose-containing  solutions,  nor  does  it  curdle  steril- 
ized milk ;  it  grows  readily  on  gelatin  plates.  Potato  cultures  of  the 
typhoid  bacillus  are,  as  a  rule,  scarcely  visible,  while  those  of  the 
colon  bacillus  appear  as  distinct,  broad,  orange  streaks.  Finally,  the 
typhoid  bacillus  does  not  yield  the  indol  reaction  with  the  ordinary 
tests,  while  the  colon  bacillus  does. 

For  diagnostic  purposes  the  most  valuable  property  connected  with 
the  bacillus  typhosus  is  the  arrest  of  motility  and  the  agglutination 
occasioned  when  brought  in  contact  with  immune  serum  or  a  culture 
of  the  typhoid  bacillus, — the  Widal  test.  The  clumping  that  occurs 
is  characteristic,  and  happens  in  from  one  to  fifteen  minutes  with  a 
dilution  of  1  to  10.  The  applicability  of  the  test  has  been  immensely 
widened  by  the  use  of  dry  blood,  as  suggested  by  Wyatt  Johnston ; 
it  is  thus  largely  employed  for  purposes  of  public  sanitation.  A  drop 
or  two  of  blood  is  collected  on  glazed  paper  and  can  be  transmitted 
to  a  laboratory  by  mail,  and  is  for  a  long  period  ready  for  testing  by 
simply  dissolving  the  dried  blood  in  water.^ 

The  Widal  reaction  is  the  most  important  of  all  recent  additions 
to  the  diagnosis  of  typhoid,  or,  indeed,  of  any  idiopathic  fever.  I 
have  used  it  very  extensively  at  the  Pennsylvania  Hospital,  and  believe 
in  its  wide  applicability.  It  gives  accurate  results  in  fully  ninety-two 
per  cent,  of  the  trials,  if  the  technique  be  careful,  and  many  of  its 
supposed  failures  are  due  to  defective  technique.  It  has,  however, 
its  limitations.  If  a  person  has  once  had  typhoid  fever  the  reaction 
may  show  itself  for  years  afterwards,  and  be  very  misleading  should 
a  fever  attack  of  doubtful  character  occur.  Then  it  is  of  little  value 
in  the  first  week  of  the  disease,  rarely  being  manifest  before  the  fourth 
day,  and  often  not  until  the  sixth  to  the  eighth  day.  It  may  not  show 
itself  until  very  late  in  the  disease.  Thus  in  one  of  my  cases  of  renal 
typhoid,  repeatedly  tested,  there  was  no  Widal  reaction  until  in  the 
fifth  week.  It  is  sometimes  obtained  where  there  is  no  clinical  e^d- 
dence  of  typhoid  fever,  though  we  must  remember,  especially  in 
hospital  practice,  the  possibility  of  the  patient  having  had  this  years 
before.  I  have  found  most  of  these  erroneous  tests  to  be  in  instances 
of  acute  rheumatism,  of  acute  tuberculosis,  and  of  nephritis. 


'  For  the  exact  and    fuller  technique,   see  works  on    bacteriology,    or    ' '  The 
Diagnosis  of  Disease,"  by  Cabot,  1899. 


FEVERS.  795 

Enlargement  of  the  spleen  is  a  very  constant  attendant  upon  the 
fever.  The  tympany  that  often  exists  interferes  with  the  recognition 
of  the  enlargement. 

Another  abnormal  symptom  of  significance  is  pain.  It  varies 
much  in  severity  and  character,  and  is,  indeed,  not  always  present. 
It  is  often  a  heavy,  aching  feeling.  In  some  patients  it  is  of  a  griping 
kind,  preceding  the  loose  discharges  ;  in  others  it  seems  to  be  called 
into  existence  only  by  pressure.  Its  most  common  seat  is  in  the  iliac 
fossae,  especially  in  the  right  iliac  fossa,  and  the  pain  corresponds, 
for  the  most  part,  to  the  seat  of  the  lesions.  In  rare  instances  the 
pain  is  really  in  the  muscles,  which  may,  indeed,  suppurate.^  Often, 
while  the  hand  is  exploring  the  abdominal  regions,  a  movement  of 
the  fluid  and  gas  in  the  distended  bowel,  attended  with  a  gurgling 
noise,  becomes  appreciable.  This  sign  is  best  elicited  near  the  ileo- 
caecal  valve. 

During  convalescence,  griping  pains  are  not  infrequently  com- 
plained of.  They  are  colicky  pains,  produced  generally  by  errors  in 
diet,  and  may  be  followed  by  a  return  of  the  diarrhoea.  But  pains 
at  almost  any  stage  of  the  disease  may  be  also  due  to  peritonitis  and 
to  perforation. 

Hardly  inferior  to  the  abdominal  symptoms  in  import  are  the  signs 
of  disturbance  of  the  nervous  system.  The  fever  is,  as  its  old  name 
implies,  pre-eminently  a  "nervous"  fever:  the  nervous  symptoms 
are,  in  truth,  never  absent ;  but,  though  always  present,  they  are  less 
extensive  in  some  cases  than  in  others,  and  not  the  same  throughout 
all  the  stages  of  the  disease.  Thus,  early  in  the  disorder,  dull  head- 
ache, mental  languor,  wakefulness,  and  a  perverted  state  of  the  senses, 
such  as  ringing  in  the  ears  and  dulness  of  hearing,  are  encountered; 
while  later,  great  restlessness,  delirium,  somnolence,  or  coma,  and 
jerking  of  the  tendons  are  phenomena  more  likely  to  be  met  with. 
Occasionally  the  disease  is  ushered  in  by  acute  mania.^  In  some 
epidemics  the  nervous  symptoms  are  so  pronounced  that  a  cerebro- 
spinal type  of  the  disorder  is  recognizable. 

The  delirium  sets  in  generally  during  the  second  Aveek,  for  the 
most  part  at  night,  and  terminates  with  convalescence  or  ends  in 
coma.  It  is  not  a  wild  delirium,  but  a  confusion  of  mind  associated 
with  rambling  thoughts.  If  the  patient's  attention  be  strongly  en- 
gaged, he  may  be  almost  always  roused,  and  does  for  a  time  as  he  is 


1  Ebing,  Archiv  fiir  klin.  Med.,  viii. 

2  Hare  and  Patek,  Medical  News,  Juiit"  20.  1891,  p.  681  ;  MacDougall,  Lancet, 
April  15,  22,  1893. 


796  MEDICAL  DIAGNOSIS. 

told ;  but  after  a  short  interval  his  muttering  lips  indicate  that  some 
curious  fancy  has  again  taken  possession  of  him.  In  some  cases,  not 
in  many,  the  delirium  is  attended  with  great  restlessness  and  agita- 
tion, and  the  sick  man,  if  not  prevented,  attempts  to  walk  about  the 
room.  This  kind  of  frenzy  often  ends  in  fatal  coma.  Equally  un- 
promising is  early  or  unremitting  delirium.  When  contrasted  with 
the  mental  wandering  in  other  acute  disorders,  the  delirium  of  typhoid 
fever  exhibits  peculiar  traits.  It  is  ordinarily  more  active  than  that  of 
typhus  ;  far  less  demonstrative  or  talkative  than  the  mania  of  drunken- 
ness ;  as  aimless  as,  but  less  continued  than,  the  ravings  of  inflamma- 
tion of  the  brain.  Great  restlessness  and  tremors,  associated  with  a 
clear  mind,  and  at  times  with  copious  perspirations,  have  a  very  sig- 
nificant meaning :  they  j)oint  to  deep  and  extending  ulceration. 

Other  symptoms  of  grave  disturbance  of  the  nervous  system  show 
themselves  in  violent  general  convulsions.  These  are  more  common 
in  children  than  in  adults,  in  whom  they  may  be  a  late  symptom ; 
they  may  or  may  not  be  of  ursemic  origin.  The  knee-jerks  are 
present,  unless  peripheral  neuritis  exists.  In  severe  cases  both  the 
reflexes  and  the  muscular  irritability  are  said  to  be  increased.'  On  the 
other  hand,  it  has  been  observed  that  in  children  the  tendon-reflexes 
are  often  enfeebled  during  the  acute  stage  of  the  disease  and  exagger- 
ated during  convalescence.- 

In  some  cases  of  typhoid  fever  symptoms  not  only  cerebral  but 
also  of  spinal  origin  appear,  and  they  may,  indeed,  assume  a  high 
degree  of  intensity.  We  find  extensive  cutaneous  hyperaesthesia, 
spinal  pain  and  tenderness,  with  a  sense  of  pricking  along  the  verte- 
bral column,  and,  in  some  instances,  cutaneous  and  muscular  anaes- 
thesia, numbness  of  the  extremities,  partial  paralysis  or  convulsive 
contractions  of  the  respiratory  muscles,  convulsive  cough,  paralysis 
of  the  sphincters,  contractions  of  the  extremities,  and  even  rigidity 
of  the  muscles  of  the  neck.  These  spinal  symptoms  are  more 
common  when  the  disease  is  epidemic  than  when  it  is  sporadic, 
and  are  always  indicative  of  a  very  serious  form  of  the  disorder. 
They  sometimes  persist  after  the  fever  has  left,  or  indeed — and  this  is 
especially  true  of  paralysis — may  not  appear  until  convalescence. 
The  pahy,  the  most  common  form  of  which  is  paraplegia,  mostly 
begins  gradually  and  disappears  gradually.  It  may  be  preceded  by 
trembling  movements,  suggesting  disseminated  sclerosis ;  but  the 
tremor  is  rather  the  result  of  general  debility,  and  is  not  associated 


^  Angel  Money,  Lancet,  Nov.  7,  1885,  p.  842. 

^  Alhouze,  Journal  de  Medecine  et  de  Chirurgie  Pratiques,  Sept.  10,  1892. 


FEVERS.  797 

with  difficulty  of  enunciation.  There  is  much  evidence  that  the  paral- 
ysis after  typhoid  fever  is  due  to  multiple  neuritis.^ 

Hawkins  -  has  reported  a  fatal  case  of  typhoid  fever  complicated 
by  intestinal  hemorrhage  and  purpuric  spots  and  the  development  of 
right  hemiplegia  and  aphasia  due  to  occlusion  of  the  left  middle 
cerebral  artery.  He  has  collected  seventeen  cases  of  typhoid  fever 
complicated  by  hemiplegia.  Most  often  the  palsy  was  right-sided  and 
associated  with  aphasia.  Usually  there  was  recovery  from  the  paral- 
ysis, but  in  three  cases  this  was  persistent.  The  complication  was 
most  common  at  the  end  of  the  attack  or  during  convalescence. 

Two  other  prominent  symptoms  of  the  malady  must  still  be  in- 
quired into :  one  is  epistaxis ;  the  other,  the  cutaneous  eruption. 
Epistaxis  is  not  often  absent  in  grave  cases.  It  may  happen  at  any 
period ;  but  it  generally  takes  place  before  the  disorder  is  far  ad- 
vanced. The  quantity  of  blood  lost  is  rarely  considerable  :  and  for 
this  reason  the  bleeding  is  frequently  overlooked. 

The  eruption  peculiar  to  the  disease  is  the  rose-colored  rash.  It 
appears  on  or  shortly  after  the  seventh  day,  but  occasionally  not  until 
the  end  of  the  second  week.  It  consists  of  small,  red  spots,  only  very 
slightly  elevated  above  the  skin,  somewhat  similar  to  flea-bites,  yet 
differing  from  them  in  lacking  the  central  mark  and  in  their  finer, 
paler  color  and  less  obvious  outline.  The  spots  are  seen  upon  the 
abdomen  and  chest,  rarely  upon  the  extremities,  almost  never  upon 
the  face.  They  disappear  totally  on  strong  pressure,  yet  return  imme- 
diately when  the  pressure  ceases ;  their  disappearance  and  reappear- 
ance are  best  studied  by  stretching  the  skin.  They  are  generally  few 
in  number,  and  not  persistent.  Each  spot  does  not  last  for  more  than 
three  or  four  days  ;  then  it  fades,  and  a  fresh  one  near  by  replaces  it, 
and  runs  the  same  course.  Spots  thus  appear  and  pass  away  for 
more  than  a  week,  after  which,  in  most  cases,  they  entirely  vanish. 
During  convalescence  not  a  trace  of  them  can  be  found.  The  erup- 
tion, although  very  common,  is  not  invariably  present;  at  all  events, 
it  is  not  invariably  found.  Beyond  doubt,  too,  it  is  in  some  epidemics 
more  constant  and  marked  than  in  others.  Late  in  the  disease 
another  eruption  appears,  consisting  of  mmute  transparent  vesicles, 
scattered  plentifully  over  the  body.  These  sudamina  are  not  so  fre- 
quently encountered  as  the  rose-rash,  and  are  not  characteristic.  As 
further,  though  rare,  eruptions  in  typhoid  fever  we  find  blue  spots,  a 

^  Pitres  and  Vaillard,  Rev.  de  Med.,  1885,  t.  v.  ;  Ross,  Amer.  Journ.  Med. 
Sci.,  Jan.  1889  ;  Bury,  Medical  Chronicle,  June,  1892. 

^  Transactions  of  the  Clinical  Society  of  London,  vol.  xxvi.,  1898,  p.  oO. 


798  MEDICAL   DIAGNOSIS. 

scarlatiniform,  or  a  measly  rash.^  There  may  be  also,  as  in  typhus, 
mottling  of  the  skin,  and  the  cerebral  spots  are  readily  produced. 
Attention  has  been  called  to  a  yellowish  discoloration  of  the  palms  of 
the  hands  and  soles  of  the  feet  in  cases  of  typhoid  fever.^ 

The  blood  in  typhoid  fever  shows  constant  reduction  in  haemo- 
globin, and  a  relatively  smaller  diminution  in  the  red  corpuscles.  But 
the  most  characteristic  point  connected  with  it  is,  as  we  know  chiefly 
through  the  admirable  researches  of  Thayer,  that  the  white  corpuscles 
remain  normal  or  are  slightly  diminished.  The  absence  of  leuco- 
cytosis  or  the  hypoleucocytosis  becomes,  indeed,  a  valuable  sign,  and 
distinguishes  typhoid  fever  from  acute  inflammatory  conditions  and 
from  septic  fevers.  Nay,  it  has  been  found  that  even  where  suppu- 
rating complications  exist,  such  as  otitis  media,  streptococcus  pneu- 
monia, decubital  abscess,  there  is  no  increase  of  the  leucocytes  above 
the  normal.^  Osier  has,  however,  observed  an  increase  in  the  poly- 
nuclear  forms  where  an  acute  inflammatory  process  occurs  in  typhoid 
fever,  as  in  connection  with  perforation. 

After  convalescence  has  set  in,  we  may  have  a  return  of  fever.  It 
may  be  either  a  transitory  and  slight  return,  due  to  fatigue  or  to  some 
indiscretion  in  diet,  or  a  more  protracted  state,  in  which  most  or  all  of 
the  symptoms  peculiar  to  the  disease  reappear.  Thus,  typhoid  fever 
relapses  usually  come  on  in  the  second  week  of  assured  convalescence, 
and,  according  to  my  experience,*  occur  suddenly ;  soon  diarrhoea, 
furred  tongue,  and  enlargement  of  the  spleen  are  manifest,  and  on  the 
fourth  or  fifth  day  reappears  the  characteristic  rose-rash,  which  is 
often  somewhat  coarser  than  in  the  first  attack,  and  does  not  show  the 
same  disposition  to  appear  in  successive  crops.  With  the  eruption 
delirium  often  comes  back.  The  temperature  is  unlike  that  of  the 
original  attack  in  quickly  reaching  a  high  point  of  fever-heat ;  after  the 
first  day  or  two  it  remains  more  or  less  stationary,  with  a  slight  morn- 
ing fall,  for  five  or  seven  days  usually,  and  then  shows  the  well-known 
remissions  and  rises  of  the  zigzag  decline.  The  relapse  is  in  its  dura- 
tion usually  much  shorter  than  the  original  attack,  and  generally,  not- 
withstanding the  threatening  appearance  of  the  symptoms,  ends  in 
convalescence.  During  its  progress  intestinal  hemorrhage  may  hap- 
pen ;  and  after  return  to  apparent  health  a  second  relapse  or  more 


^  For  a  description  of  these  anomalous  rashes,  see  a  paper  of  mine,  Amer. 
Journ.  Med.  Sci.,  July,  1899. 

-  Filipovitch,  Lancet,  Aug.  19,  1893.     See  also  Med.  News,  Oct.  4,  1893,  p.  444. 

^  Kolner,  Deutsch.  Arch.  f.  klin.  Med. ,  Bd.  Ix. 

*  See  article  on  Relapses  of  Typhoid  Fever,  Transactions  of  the  College  of 
Physicians  of  Philadelphia,  1877. 


FEVERS.  799 

may  occur.  Each  relapse  occasions  characteristic  markings  on  the 
nails,  from  impaired  nutrition,  which  Longstreth  has  very  fully  de- 
scribed.^ Ziemssen  specifies  the  fifth,  seventh,  and  fourteenth  days 
after  the  cessation  of  the  original  fever  attack  as  the  days  on  which  a 
relapse  is  likely  to  happen.^  The  temperature  sometimes  keeps  up  a 
degree  or  tv^^o,  while  the  patient  is  in  every  other  respect  fully  conva- 
lescent, yet  will  come  speedily  to  the  norm  if  he  be  made  to  leave  his 
bed. 

Both  during  the  height  of  the  fever  and  in  convalescence,  but 
more  especially  during  the  latter,  certain  complications  or  sequelae  may 
arise,  some  of  which  are  medical,  such  as  parotitis,  swelling  of  the 
submaxillary  glands,  otitis  media,  erysipelas,  noma,  laryngeal  ulcera- 
tion or  stenosis,  milk-leg,  thrombosis  of  the  femoral  artery,  the  result 
of  arteritis,^  jaundice,  acute  cholecystitis,  abscess  of  the  liver,  perios- 
titis, osteomyelitis,  gangrene  of  the  skin,^  transitory  aphasia,''  hemi- 
plegia, paraplegia,  hysteria,  local  neuritis,  tenderness  of  the  toes, 
pseudo-dementias,  and  insanity ;  while  others,  as  dislocations,  caries, 
necrosis  of  bones,  epididymitis,*'  orchitis,^  vesicular  catarrh,  abscess, 
and  gangrene,  come  within  the  domain  of  surgery.^ 

Among  the  medical  complications  a  few  must  be  specially  exam- 
ined into,  as  they  may  involve  grave  questions  of  operative  procedure. 
To  these  belong  some  of  the  hepatic  complicatioiis.  Now,  while  jaun- 
dice is  a  rare  symptom  in  enteric  fever,  hepatic  complications  are  not. 
I  have  collected  fifty-five  cases  of  jaundice,  eight  of  which  were  my 
own,^  and  they  occurred  in  various  conditions, — some,  not  many,  were 
catarrhal,  others  were  connected  with  abscess  or  with  acute  yellow 
atrophy  of  the  liver,  or  with  pylephlebitis,  or  with  acute  cholecystitis ; 
the  majority  were  of  blood  origin.  By  far  the  largest  number  of 
hepatic  disorders  in  typhoid  fever   occur  without  jaundice,  and  are 

'  Relapses  of  Typhoid  Fever,  Transact.  Coll.  of.  Phys.  of  Phila.,  1877. 

2  Arch.  f.  klin.  Med.,  Feb.  1884. 

3  Lucas-Championniere,  Journ.  de  Med.  et  de  Chir.  Pratiques,  1888. 

*  Stahl,  Phila.  Med.  Journal,  Oct.  1898,  and  Transactions  of  the  College  of 
Physicians  of  Philadelphia,  1899. 

°  Arch.  f.  klin.  Med.,  Bd.  xxxiv.,  1,  1883. 

•■'  Girode,  Archives  Gen.  de  Medecine,  Jan.  1892,  p.  43. 

■  Eshner,  Phila.  Med.  Journ.,  May, '1898. 

^  See  an  admirable  discussion  of  these  surgical  complications  in  the  work, 
"On  the  Surgical  Complications  and  Sequelse  of  Typhoid  Fever,"  1898,  by  Dr.  W. 
W.  Keen. 

"See  papers  "On  the  Significance  of  Jaundice  in  Typhoid  Fever,  and  on  the 
Hepatic  Complications  without  Jaundice."  in  Amer.  Journ.  Med.  Sci.,  July,  1898, 
and  "On  Cases  of  Cholecystitis  ending  in  Recoverj^"  ibid.,  Aug.  1899. 


800  MEDICAL  DIAGNOSIS. 

very  difficult  to  recognize, — may  be,  indeed,  entirely  latent.  Tliis  is 
especially  true  of  the  gall-bladder  infection,  and  the  secondarily  in- 
duced cholecystitis.  Gall-bladder  infection  is  so  common  in  typhoid 
fever  as  to  be  the  rule  ;  gall-bladder  symptoms  are  the  exception.  Yet 
cholecystitis,  if  looked  for,  is  oftener  found  than  appears  at  first  sight. 
Its  symptoms  are  the  same  as  when  not  due  to  bacillary  typhoid  infec- 
tion :  severe  pain,  tenderness,  tumor,  nausea,  and  vomiting. 

The  appendix  is  not  infrequently  the  seat  of  typhoid  ulcers,  and 
they  may  even  lead  to  perforation.  Yet  ap]jendicitis  with  distinct 
symptoms,  and  as  a  recognizable  complication,  is  a  very  rare  disease. 
But  I  have  seen  several  instances  of  it.  The  localized  tenderness  at 
or  near  McBurney's  point,  a  peritonitis  spreading  from  there,  rigidity 
of  the  right  rectus  muscle,  sense  of  resistance  or  circumscribed 
tension  in  the  right  Uiac  fossa,  and  vomiting  are  the  most  significant 
symptoms.  Deaver  ^  lays  stress  on  the  nausea  and  vomiting  ceasing 
when  the  pain  becomes  localized  in  the  right  iliac  fossa ;  there  may  or 
may  not  be  the  history  of  a  previous  attack.  The  symptoms  may  con- 
tinue for  a  considerable  time  and  slowly  subside,  or  perforation,  or  an 
abscess  follow.  Hare  -  has  recorded  a  case  in  which  in  the  course  of 
typhoid  fever  a  perityphlitic  abscess  formed,  and  in  wdiich  recovery 
followed  an  operation.     There  was  decided  leucocytosis. 

The  worst  of  the  complications  of  typhoid  fever  is  perforation. 
This  occurs  in  from  two  to  two  and  a  half  per  cent,  of  the  cases,  and 
it  is  asserted  to  be  rather  more  common  when  the  bath  treatment  has 
been  employed.  It  is  much  more  usual  in  men  than  in  women,  and 
is  very  generally  fatal.  The  accident  usually  happens  at  the  end  of 
the  third  week,  or  later,  though  it  is  not  extremely  infrec|uent  in  the 
second  week.  At  times  the  symptoms  of  perforation  are  latent,  and 
masked  by  the  general  gravity  of  the  case,  and  the  great  meteorism  ; 
it  is  only  at  the  autopsy  that  the  perforation  is  found.  When  perfora- 
tion occasions  symptoms,  these  are  of  two  kinds  ;  there  is  either  col- 
lapse followed  by  peritonitis,  or  there  is  a  spreading  peritonitis  with- 
out the  signs  of  collapse.  In  the  first  case  we  meet  with  sudden 
acute  abdominal  pain,  referred  to  the  lower  part  of  the  abdomen, 
vomiting,  signs  of  prostration,  pinched  features,  rigidity  of  the  recti 
muscles,  at  times  fall  of  temperature,  and  subsequently  chills,  elevated 
temperature,  local  tenderness,  followed  by  spreading  peritonitis.  In 
the  second  case  the  peritonitis  alone  is  marked,  and  is  attended  or 
not  with  tympanitic  distention  or  vomiting  or  sweats,  but  always  with 


^  Amer.  Journ.  Med.  Sci.,  Jan.  1898. 

^  Medical  Complications  and  Sequels  of  Typhoid  Fever,  1899. 


FEVERS.  801 

obviously  increasing  gravity  of  the  case.  Under  either  set  of  circum- 
stances great  diminution  of  the  hepatic  duhiess  is  a  vahiable  sign.  To 
this  may  be  added  marked  leucocytosis,  as  found  by  Thayer.  The 
same  symptoms  as  those  of  intestinal  perforation  may  be  due  to  per- 
foration of  the  appendix  or  of  the  gall-bladder  in  typhoid  fever,  and 
no  distinction  is  possible,  unless  the  exact  seat  of  the  pain  and  of  the 
early  peritonitis  and  the  history  of  the  case  enable  us  to  make  it. 

Occasionally,  unfortunately  not  often,  inflammatory  adhesions  close 
the  perforation  and  recovery  ensues  without^  an  operation  ;  or  a  local- 
ized abscess  results.  The  peritonitis  and  intestinal  adhesions  that 
follow  perforation  may  be  attended  with  symptoms  of  obstruction  of 
the  bowel.^ 

Sometimes  sequelae  appear  long  after  the  primary  disease  has  come 
to  an  end.  Orlow  -  has  reported  a  case  in  which  five  and  one-half 
months  afterwards  typhoid  bacilli  were  detected  in  a  granuloma  of 
the  tibia.  Pean  and  CornU "  obsen^ed  a  case  in  which  five  months 
after  a  typhoid-fever  attack  typhoid  bacilli  were  found  in  the  lesions 
of  a  suppurative  periostitis,  and  Van  Dungern^  reports  an  instance 
of  typhoid  bacilli  met  with  in  the  pus  from  an  abscess  around  the 
gall-bladder  fourteen  and  a  half  years  after  the  attack.  Sudden  death 
may  take  place  in  the  course  of  typhoid  fever  as  a  result  of  disturb- 
ances in  the  circulation,  from  the  formation  of  blood-clots,  from 
inflammatory  and  degenerative  changes  in  the  muscular  wall  or  dis- 
order of  the  nervous  supply  of  the  heart,  or  from  the  poisoning  of 
the  system  that  is  an  essential  part  of  the  disease.^  Death  has  also 
resulted  from  profuse  sweating.'' 

The  disorders  with  which  typhoid  fever  may  be  confounded  are 
not  the  same  at  all  the  stages  of  the  complaint.  Early  in  the  affec- 
tion it  is  most  likely  to  be  mistaken  for  simple  continued  fever,  for  in- 
fluenza, or  for  one  of  the  exanthemata.  But  diarrhoea  is  not  present 
in  these,  nor  are  there  marked  prodromata;  and  whatever  doubt 
may  exist  with  reference  to  the  first  two  is  cleared  up  in  a  few  days, 
since  the  temperature-record  is  different  and  the  acute  symptoms 
generally  come  to  an  end  at  a  time  at  which  in  typhoid  fever  they 
begin  to  be  more  and  more  developed.     The  exanthematous  fevers 


1  Blaikie  Smith,  International  Clinics,  vol.  i.,  2d  Series,  1892,  p.  79. 

2  Deutsche  Medicin.  Wochenschiifl,  Nov.  27,  1890. 

'  Bull,  de  FAcademie  de  Medecine  de  Paris,  April  14,  1891. 
*  Munch.  Med.  Wochenschr.,  1897,  No.  26. 

■' Dewevre,  Archives  Generates  de  Mfklecine,  Oct.,  Dec.  1887  ;  Galliard.  ibid., 
May,  June,  1891. 

•*  Juhel-Renoy,  Archives  Generates  de  Medecine;  1886,  vol.  i.  p.  274. 


802  MEDICAL   DIAGNOSIS. 

cannot,  before  their  eruptions  appear,  be  distinguished  with  absolute 
certainty ;  though  we  may  suspect  measles  by  the  coryza,  scarlatina 
by  the  sore  throat,  and  smallpox  by  the  lumbar  pains  and  high  fever. 

At  a  more  advanced  period,  typhoid  fever  may  be  confounded  with 
typhus,  and  with  these  morbid  states  : 

General  Debility  ; 

Typhoid  Conditions  ; 

ENTEmTis  ; 

Peritonitis  ; 

Appendicitis  ; 

Meningitis  ; 

Ulcerative  Endocarditis  ; 

Acute  Pulmonary  Affections. 

General  Debility. ^-li  does  not  seem  likely  that  so  acute  and  dan- 
gerous a  malady  as  typhoid  fever  could  be  mistaken  for  mere  debility ; 
yet  such  an  error  may  occur  when  the  disease  is  latent,  or  so  light  as 
not  to  confine  the  patient  to  bed.  In  these  so-called  "  walking  cases" 
the  debility,  however,  sets  in  suddenly,  and  not  gradually,  as  in  weak- 
ness from  general  constitutional  causes.  Moreover,,  the  abdominal 
symptoms  are  rarely  wanting,  and  there  is  more  or  less  confusion 
of  mind.  The  thermometer  is  of  signal  value.  But  the  greatest  safe- 
guard against  error  is  to  be  aware  that  the  disease  assumes  at  times  a 
latent  form,  and  to  examine  every  case  of  sudden  debility,  to  see  if 
under  its  mask  are  hidden  the  features  of  typhoid  fever. 

Typhoid  Conditions. — No  blunder  is  more  common  than  to  mis- 
construe into  typhoid  fever  a  typhoid  condition  of  the  system.  We 
may  find  this  condition  in  many  different  complaints,  both  acute  and 
chronic ;  but  more  especially  are  purulent  infection,  some  forms  of 
pneumonia,  dysentery,  erysipelas,  and  abscess  of  the  kidney  attended 
with  delirium,  drowsiness,  dry,  brown  tongue,  and  extreme  prostra- 
tion,— in  one  word,  with  a  typhoid  state. 

Yet  a  typhoid  state  is  not  typhoid  fever ;  it  is  simply  a  low  condi- 
tion of  the  system  which  may  be  present  in  many  dissimilar  maladies, 
and  which  is  present  in  its  most  perfect  form  in  typhoid  fever.  But 
in  this  disease  we  have  other  signs  than  those  of  adynamia :  we  find 
joined  to  it  diarrhoea,  tympanites,  epistaxis,  an  eruption,  special  mani- 
festations of  disturbance  of  the  nervous  system,  a  peculiar  tempera- 
ture record,  and  the  very  significant  Widal  reaction  and  absence  of 
leucocytosis.  What  exactly  produces  the  typhoid  state  it  is  difficult 
to  say.     Milner  Fothergill  ^  connects  it  with  tissue-waste  without  in- 

^  Edinburgh  Medical  Journal,  Sept.  1873. 


FEVERS.  803 

creased  renal  activity,  and  with  the  accumulation  in  the  blood  of  the 
products  of  the  tissue-waste. 

At  times  we  meet  with  a  fever  attended  with  typhoid  symptoms 
and  diarrhoea  due  to  contammated  drinking-water.  The  septic  fever, 
of  which  on  one  occasion  I  saw  a  number  of  instances  at  the  Penn- 
sylvania Hospital  among  sailors,  from  drinking  bilge- water,  is,  how- 
ever, of  comparatively  short  duration,  and  has  not  the  characteristic 
temperature  record  or  eruption  of  typhoid  fever. 

Enteritis. — The  great  difference  between  enteritis  and  typhoid 
fever  consists  in  this :  in  enteritis  the  inflammation  of  the  intestine 
constitutes  the  disease ;  there  are  no  symptoms  other  than  those 
referable  to  the  inflamed  intestine.  We  find  no  great  prostration  ;  no 
mental  wandering ;  no  enlargement  of  the  spleen ;  no  rose-spots ;  no 
signs  of  abnormal  processes  due  to  a  typhoid  dyscrasia.  The  dis- 
order, too,  gives  rise  to  much  more  abdominal  pain,  and  is  of  shorter 
duration.  In  certain  rare  cases  the  follicles  of  the  intestines  are  in- 
flamed and  swollen,  and  the  attending  febrile  malady  may  closely 
simulate  typhoid  fever,  without,  however,  its  characteristic  intestinal 
lesions,  or  eruption,  though  with  considerable  diarrhoea  and  swelling 
of  the  spleen.^  Again,  I  have  known  fecal  accumulations  in  the  in- 
testine to  produce  and  keep  up  diarrhoea  and  continued  fever  of  sev- 
eral weeks'  duration  similar  to  that  of  typhoid,  and  ceasing  only  when 
the  large  fecal  masses  were  voided.  The  absence  of  eruption,  of 
cerebral  symptoms,  and  of  enlargement  of  the  spleen  proved  the 
points  on  which  the  correct  diagnosis  of  the  non-existence  of  typhoid 
fever  was  based.     In  all  such  cases  the  Widal  test  would  be  of  value. 

Peritonitis. — The  same  remarks  apply  to  peritoneal  inflammation. 
Here,  moreover,  the  expression  of  the  face,  the  constipation,  and  the 
great  abdominal  tenderness  serve  as  marks  of  discrimination.  The 
low  continuous  fever  in  tubercular  peritonitis  may  be  very  misleading, 
as  well  as  the  gradual  development  of  the  disease  and  the  tympanitic 
distention.  But  the  history  of  the  case,  the  irregularity  of  the  fever, 
the  supervention  of  ascites  become  very  significant.  On  the  other 
hand,  w^e  must  not  forget  that  acute  peritonitis  may  appear  in  the 
course  of  typhoid  fever.  Generally  this  untoward  event  happens  at 
a  late  period  of  the  disease,  and  is  connected  with  intestinal  perfora- 
tion, and,  as  a  general  diagnostic  rule,  we  are  right  in  assuming,  when 
peritonitis  is  found  in  typhoid  fever,  that  there  has  been  perforation. 
But  in  very  rare  cases  there  is  no  such  association. 

Appendicitis. — The  differential  diagnosis  between  typhoid  fever  and 


^  Cazalis  and  Renaut,  Archives  de  Physiologic,  1873. 


804  MEDICAL   DIAGNOSIS. 

appendicitis  has  been  inquired  into  with  the  latter  affection  ;  their 
coexistence  has  been  just  mentioned  with  the  complications  of  typhoid 
fever. 

Meningitis. — Typhoid  fever  lias  some  symptoms  in  common  with 
inflammation  of  the  brain ;  but  the  signs  of  difference  have  been  dis- 
cussed in  connection  with  acute  meningitis,  and  need  not  here  be 
examined.  The  temperature  record  is  very  significant,  and  Kernig's 
sign  is  said  to  be  absent.^  But  in  rare  cases  we  really  have  meningitis 
as  a  complication  of  typhoid,  showing  small  pupils,  strabismus,  vomit- 
ing, and  rigid  neck ;  in  the  exudate  in  the  meninges  typhoid  bacilli 
have  been  found.  The  distinction  from  epidemic  cerebro-spinal  men- 
ingitis we  shall  presently  trace. 

Ulcerative  Endocarditis. — In  some  cases  the  differential  diagnosis 
between  this  and  typhoid  fever  becomes  of  great  difficulty,  especially 
if  the  case  be  not  seen  until  the  endocarditis  have  led  to  delirium  and 
the  symptoms  of  collapse.  Recurring  chills,  with  high  temperature 
and  sweats,  as  in  malarial  fever,  great  rapidity  of  pulse,  with  sudden 
changes  and  marked  irregularity,  a  generally  diffused  roseolous  erup- 
tion, and  the  signs  of  the  cardiac  lesion,  form  the  most  trustworthy 
points  of  distinction.    • 

Acute  Pulmonary  Affections. — In  the  majority  of  cases  of  typhoid 
fever  we  find  cough,  dependent  upon  an  ajEfection  of  the  bronchial 
tubes.  The  bronchial  affection  gives  rise  to  extreme  loudness  of  the 
rales,  with  a  cough  disproportionately  slight ;  sometimes,  too,  owing 
to  the  blood  gravitating  to  the  most  dependent  portions  of  the  lungs, 
the  resonance  over  the  posterior  part  of  the  chest  is  impaired.  From 
these  phenomena,  added  to  the  abdominal  and  cerebral  symptoms  of 
the  fever,  the  eruption,  and  the  vital  depression,  there  is  no  difficulty 
in  discriminating  between  idiopathic  bronchitis  and  typhoid  fever. 

Not  infrequently  we  find  a  dry  pleurisy  combined  with  the  bron- 
chitis, and  in  some  cases,  not  in  many,  the  cough  is  associated  Avith 
exudation  into  the  pulmonary  structure.  Now,  it  may  be  extremely 
difficult  to  distinguish  r  pneumonia  of  this  kind  from  inflammation  of 
the  lung  setting  in  amid  signs  of  prostration,  until  the  eruption  and 
the  abdominal  symptoms  solve  the  difficulty.  Generally,  however,  it 
is  not  a  matter  of  much  doubt,  as  the  condensation  of  the  lung  in 
typhoid  fever  does  not  occur  early  in  the  disease, — not,  in  fact,  until 
the  symptoms  of  the  fever  are  clearly  developed. 

At  times,  however,  typhoid  fever  sets  in  acutely  with  the  signs  of 
acute  lobar  pneumonia ;  there  is  a  chill,  followed  by  high  fever ;  there 

1  Keller,  Revue  des  Maladies  de  rEnfance,  Sept.  1898. 


FEVERS.  805 

are  no  abdominal  symptoms.  The  lung  consolidation  does  not  mi- 
dergo  resolution,  and  in  the  second  week  or  later  diarrhoea  appears, 
and  the  characteristic  eruption  of  tjqohoid  fever  may  or  may  not  show 
itself.  The  general  typhoid  condition  gradually  becomes  marked.  It 
is  very  difficult  to  distinguish  these  cases  of  so-cRiled  pneumo-typhus 
— chiefly  described  by  Wagner^  and  other  German  observers — from 
pneumonia  of  a  low  type  ;  they  depend  upon  early  and  extreme  bacil- 
lary  infection  of  the  lungs.  The  eruption,  when  present,  is  very  valu- 
able, as  is  the  Widal  reaction. 

Occasionally  a  cough  remains  after  the  typhoid  fever  has  left.  The 
patient  soon  loses  the  strength  he  may  have  acquired  ;  the  temperature 
is  again  higher,  and  over  both  lungs  many  fine,  dry,  or  moist  sounds 
are  heard.  The  percussion-note  is  here  and  there  dull ;  profuse  ex- 
pectoration, dyspnoea,  and  excessive  sweating  are  noticed.  An  exam- 
ination of  the  sputum  shows  that  the  case  has  become  tubercular. 
But,  as  regards  the  lung  symptoms  of  typhoid  fever,  we  must  always 
bear  in  mind  that  acute  pulmonary  tuberculosis  may  simulate  it ;  the 
high  fever,  the  prostration,  the  scattered  rales  in  the  chest,  with  here 
and  there  spots  of  dulness,  even  the  delirium,  the  stupor,  and  the 
enlargement  of  the  spleen  may  be  present ;  but  the  eruption  never  is, 
and  the  diarrhoea  rarely.  In  general  acute  miliary  tuberculosis  the 
similarity  is  even  greater,  and  diarrhoea  is  not  uncommon ;  the  dis- 
ease is,  as  a  rule,  longer.  Tubercle  bacilli  may  or  may  not  be  present 
in  the  sputum  ;  they  have  been  detected  in  the  urine  and  in  the  blood  ; 
when  present  they  enable  us  to  make  a  positive  diagnosis.  In  rare 
instances  the  two  diseases  coexist. 

In  concluding  the  subject  of  typhoid  fever  it  will  be  proper  to  notice 
those  forms  of  the  affection  which  run  their  course  in  a  different  man- 
ner from  that  ordinarily  pursued  by  the  malady, — there  are  especially 
two, — the  mild  typhoid  and  the  abortive  typhoid.  The  former  has  usu- 
ally a  gradual  beginning,  and  the  disease  throughout  remains  mild ; 
its  duration  may  be,  however,  the  same  as,  or  even  longer  than,  that 
of  ordinary  typhoid,  or  it  may  be  considerably  shorter, — in  fact,  an 
abortive  typhoid,  the  variety  of  typhoid  to  which  Jiirgensen  especially 
has  directed  attention.^  Yet  the  abortive  type  is  not  always  mild  ; 
cases  are  mentioned  Mn  which  the  temperature  rose  to  106°,  but  in 
which  the  duration  of  the  fever  was  only  from  seven  to  twelve  days. 

1  Archiv  fiir  klin.  Med.,  Aug.  1884. 

^  Sammlung  klinischer  Vortrage,  No.  (51,  1873.  See  also  paper  by  Johnston, 
Amer.  Journ.  Med.  Sci.,  Oct.  1875. 

^  Liebenneister.  in  Ziemssen's  Cycloi)an]iii. 


806  MEDICAL  DIAGNOSIS. 

Indeed,  it  is  the  short  duration  that  is  characteristic  of  abortive  typhoid. 
As  a  rule,  it  begins  suddenly,  and  the  temperature  reaches  its  highest 
point  on  the  second  or  third  day.  It  often  does  not  exceed  104°,  and 
it  stays  at,  or  near,  the  height  it  has  so  speedily  attained  for  the  greater 
part  of  the  duration  of  the  fever,  and  then  remissions  show  them- 
selves, and  there  is  a  gradual  return  to  a  healthy  standard,  much  in 
the  same  way  as  at  the  end  of  ordinary  typhoid  fever ;  or  the  changes 
are  so  marked  and  rapid  that  the  defervescence  is  accomplished  in  a 
few  days.  The  symptoms  of  typhoid  fever  are  all  met  with  in  the 
abortive  malady,  though  they  are  not  present  with  the  same  con- 
stancy ;  tenderness  in  the  right  iliac  fossa  is  .the  most  frequent ;  en- 
largement of  the  spleen  and  the  rose-colored  spots  are  very  usual ; 
diarrhoea  is  often  wanting.  The  disease  terminates  in  sixteen  days  or 
less ;  but  there  is  great  proneness  to  relapses.  It  is  not  apt  to  be  a 
fatal  affection.     I  am  certain  it  is  one  very  rarely  seen  in  this  country. 

Much  has  been  said  about  mountain  fevei\  especially  as  it  has  been 
observed  in  Colorado  and  other  mountainous  regions  of  the  Western 
States,  being  a  separate  form  of  fever.  But  it  is  not ;  it  is  an  irregular 
form  of  typhoid  in  which  the  eruption  is  often  absent.  The  observa- 
tions of  Woodruff^  and  of  Raymond,  who  got  characteristic  reactions 
with  the  Widal  test,  remove  any  doubt  as  to  its  nature  that  may  have 
existed.     Bradycardia,  or  slowness  of  pulse,  is  often  present.^ 

Another  variety  of  typhoid  fever  is  occasioned  by  the  coexistence 
with  malaria.  The  manifestations  of  this  occur  mostly  late  in  the 
disease,  and  chills  are  apt  to  call  our  attention  to  the  character  of  the 
malady.  But  chihs  often  happen  from  other  causes  in  typhoid  fever : 
from  cholecystitis,  from  peritonitis,  from  appendicitis,  from  pyaemia, 
from  masturbation, — of  which  I  once  saw  a  striking  illustration, — 
from  the  decided  use  of  antipyretics,  especially  the  coal-tar  prepara- 
tions, and  sometimes  without  discernible  cause.  To  be  sure  that  the 
chills  in  typhoid  fever  are  malarial,  we  must  find  the  malarial  organ- 
isms. But  we  shall,  farther  on,  examine  the  association  of  malaria 
with  typhoid  fever  more  in  detail. 

In  conclusion,  the  interesting  question  arises,  In  how  far  can  we 
recognize  typhoid  fever  without  intestinal  lesions  f  We  now  know  that 
this  happens  ;  the  bacillus  typhosus  has  been  found  in  the  gall-bladder, 
gall-ducts,  lungs,  and  elsewhere,  and  there  has  been  a  positive  Widal 
reaction  without  any  other  marked  sign.  As  yet  we  are  not  in  a  con- 
dition to  be  sure  of  such  a  form  of  typhoid  fever.  There  is  always 
the  possibility  of  a  previous  attack  of  typhoid  being  the  cause  of  the 


1  Amer.  Journ.  Med.  Sci.,  March,  1898.  ^  Raymond,  ibid. 


FEVERS.  807 

Widal  reaction.  But  it  is  a  question  whether  irregular  forms  of  fever, 
with  persistent  shght  elevations  of  temperature  and  general  depres- 
sion, for  which  no  organic  cause  can  be  found,  or  many  of  the  in- 
stances of  afebrile  typhoid  fever,  are  not  illustrations  of  this  kind  of 
typhoid  infection. 

Typhus  Fever. — This  is  a  highly  contagious  malady,  almost 
ahvays  met  with  in  an  epidemic  form.  It  prevails  in  jails  and  camps, 
among  crowded,  underfed  populations,  or  in  badly  ventilated  locali- 
ties, and  has  no  constant  structural  lesion.  In  this  country  it  is  a 
very  rare  disease  ;  indeed,  it  is  becoming  rarer  everywhere.  It  is 
either  preceded  by  a  brief  stage  of  lassitude  and  dejection,  or  is 
ushered  in  with  a  chill  and  pain  in  the  head  and  back.  The  skin 
soon  becomes  dry  and  of  pungent  heat ;  the  pulse  rises  much  in  fre- 
quency, and  is  at  first  full,  sometimes  even  tense.  The  patient  lies  in 
a  state  of  half-consciousness,  dull,  drowsy,  weak,  with  evident  signs  of 
his  nervous  and  muscular  system  being  overwhelmed  by  the  influence 
of  some  fearfully  depressing  poison.  There  is  headache  and  giddi- 
ness ;  the  face  is  flushed,  the  eye  injected;  the  odor  from  the  body 
extremely  unpleasant. 

By  the  fifth  day  all  these  symptoms  are  plainly  marked,  and  about 
this  time  a  coarse,  red  eruption  makes  its  appearance.  But  it  occa- 
sions no  change  in  the  gravity  of  the  symptoms.  On  the  contrary, 
these  increase ;  the  patient  wanders,  picks  at  his  bedclothes,  and 
ceases  to  complain  of  the  pain  in  the  head  or  limbs.  The  pulse  is 
frequent  and  feeble ;  the  tongue  dry  and  dark  ;  sordes  collect  on  the 
gums  and  teeth.  The  bowels  remain  as  they  were  at  the  onset, — 
constipated.  The  urine  often  comes  away  drop  by  drop,  or,  as  the 
bladder  loses  the  power  of  contracting,  is  retained.  The  case  has 
now  reached  its  height ;  the  signs  of  a  prostrated  nervous  system,  of 
deteriorated  blood,  and  of  utter  loss  of  muscular  strength  either  begin 
to  pass  away,  or  deepen  from  hour  to  hour  and  clearly  show  the 
doom  that  awaits  the  fever-stricken  patient.  From  the  beginning  of 
the  distemper  until  the  unfortunate  issue  is  rarely  over  thirteen  days. 
If  the  sick  man  can  withstand  the  poison  until  the  third  week,  he  is 
apt  to  throw  it  off  and  recover ;  but  it  may  be  so  virulent  as  to  over- 
power him  almost  at  the  onset.  _ 

Micro-organisms  have  been  found  in  cases  of  typhus  fever,  though 
it  is  not  certain  that  they  are  characteristic.  Dubief  and  Bruhl  ^  have 
found  a  diplococcus,  chiefly  in  the  lungs  and  bronchial  secretions,  that 
they  designate  "  diplococcus  exanthematicus."     Andrew  Balfour  and 


Univcrsiil  Medinal  Juunial,  May,  1893. 


808  MEDICAL  DIAGNOSIS. 

Porter^  isolated  a  cliplococcus  not  identical,  detected  also  in  the  blood 
which  retained  the  stain  by  Gram's  method,  and  which  they  believe 
to  be  the  specific  bacillus. 

Let  us  examine  some  of  the  symptoms  of  the  pestilential  disease : 

The  skin  is  covered  with  a  characteristic  eruption,  from  which  the 
disease  takes  its  name  of  "  spotted"  or  "  maculated"  or  "  exanthe- 
matic"  typhus.  The  rasli  is  at  first  slightly  elevated  and  much  like 
that  of  measles.  It  is  of  a  dark  tint,  a  "  mulberry  rash,"  and  fades 
but  does  not  vanish  on  pressure.  It  makes  its  appearance  from  the 
fifth  to  the  seventh  day,  and  is  permanent,  consisting  not  of  successive 
eruptions,  but  of  the  same  spots,  which  deepen  or  lighten  with  the 
changes  in  the  disease,  and  do  not  pass  away  before  the  fourteenth 
day.  Each  spot  thus  lasts  until  recovery  or  until  death,  and  no  new 
ones  show  themselves  after  the  second  or  third  day  of  the  rash. 
They  are  numerous  on  the  trunk  and  the  extremities,  but  are  rarely 
observed  upon  the  face.  Some  are  much  lighter  than  others,  and 
thus  a  mottled  aspect  of  the  skin  is  produced.  Sometimes  the  spots 
are  of  purple  color  and  uninfluenced  by  pressure.  These  petechise 
are  attendants  of  the  worst  forms. 

The  skin  of  a  typhus-fever  patient  is  often  sensitive,  and  generally 
very  hot.  In  some  cases  the  thermometer  indicates  a  temperature  of 
107°,  or  more;  commonly  it  ranges  above  104°.  The  heat  is  sus- 
tained :  it  does  not  show  the  decided  differences  between  morning  and 
evening  that  are  observed  in  typhoid  fever,  the  daily  variations  to  the 
middle  of  the  second  week  being  rarely  one  degree  ;  and  from  that  time 
onward  the  morning  abatement  does  not  amount  to  more  than  about 
1.5°,  until  the  defervescence  is  reached.  The  passing  away  of  the 
high  temperature  occurs,  however,  not,  as  in  enteric  fever,  by  more 
and  more  evident  remissions,  but  suddenly.  Early  in  or  towards  the 
middle  of  the  third  week  the  temperature  falls  quickly,  and  in  twenty- 
four  or  thirty-six  hours  a  normal  standard  is  reached.  In  rare 
instances,  the  temperature  may  not  rise  above  the  normal,  or  may  be 
subnormal,^ 

The  cerebral  symptoms  of  typhus  fever  are  never  absent.  Stupor 
is  frec|uent.  The  patient  lies  in  a  heavy  slumber,  occasionally  mutter- 
ing some  incoherent  words  ;  or  he  is  sleepless,  his  eyes  remain  wide 
open,  he  has  coma-vigil,  he  takes  no  notice  of  anything  going  on 
around  him.     Either  of  these  states  may  deepen  into  coma.     In  other 


^  Edinb.  Med.  Journ.,  Feb.  1899. 

^  Combemale,  Gazette  hebdom.  de  Medecine  et  de  Chirurgie,  1893,  No.  30,  p. 
352. 


FEVERS.  809 

cases  delirium  is  the  most  conspicuous  symptom.  Ttiis  delirium 
rarely  sets  in  before  the  end  of  the  first  week.  In  type  it  is  low  and 
muttering,  and  unaccompanied  by  great  restlessness ;  or  it  may  be 
associated  with  constant  movements  and  trembling  of  the  limbs,  or 
jerking  of  the  tendons, — in  fact,  with  hysterical  symptoms.  Some- 
times the  mental  wandering  is  active  and  very  persistent.  The  patient 
can  hardly  be  restrained  from  getting  out  of  bed.  He  has  illusions  of 
hearing  and  of  sight ;  his  eyes  are  injected,  the  pupils  often  contracted  ; 
there  is  headache,  with  intolerance  of  light.  Here  we  have  the  true 
brain  typhus,  with  its  formidable  cerebral  symptoms  simulating  closely 
those  of  acute  meningitis,  and  differing  only  by  their  union  with  a 
cutaneous  eruption,  by  the  absence  of  strabismus  and  of  rigidity  of  the 
neck,  by  the  dissimilar  aspect  of  the  tongue,  the  great  prostration,  and 
by  the  beat  of  the  pulse,  which  is  rarely  full,  and  never  so  tense  as 
that  of  meningitis.  Convulsions,  should  they  occur,  are  generally  of 
uraemic  origin. 

The  head-symptoms  of  typhus  are,  like  those  of  enteric  fever, 
sometimes  connected  with  a  noisy,  shallow,  and  irregular  respiration. 
This  kind  of  breathing  can  be  clearly  traced  to  the  abnormal  state  of 
the  nervous  system,  as  no  signs  of  alteration  in  the  lungs  coexist. 
Often,  as  Flint  ^  has  pointed  out,  it  is  a  forerunner  of  fatal  coma.  In 
one  case  I  found  the  strange  phenomenon  associated  with  distention  of 
the  bladder,  and  subsiding  after  the  introduction  of  a  catheter. 

The  remarks  with  reference  to  the  cerebral  phenomena  of  typhus 
apply  to  those  instances  in  which  there  is  no  inflammatory  disorder 
within  the  cranium.  But  we  must  not  overlook  the  fact  that  this  may 
ensue.  Such  cases  are  difficult  of  recognition.  The  pulse,  as  a  rule, 
is  slow  and  irregular,  the  pupils  are  contracted,  there  is  a  frown  on 
the  forehead,  and  intense  headache,  sometimes  screaming.  Vomiting 
is  not  always  encountered.  The  morbid  appearances  may  be  con- 
fined chiefly  to  the  base  of  the  brain.^ 

The  pwfee,  after  the  disease  is  fully  developed,  is  generally  rapid, 
and  of  moderate  volume  or  feeble.  The  beat  of  the  heart  may  be 
excited  and  violent,  while  the  pulse  is  very  weak.  Often  the  cardiac 
impulse  undergoes  a  great  diminution,  and  with  its  change  the  first 
sound  becomes  enfeebled ;  in  fact,  it  is  sometimes  almost  lost,  and 
only  very  gradually  regains  its  natural  tone.  Occasionally,  at  the 
height  of  the  disease,  it  is  replaced  by  a  soft,  systolic  murmur  of 
blood  origin. 


'  Clinical  Reports  on  Continued  Fever. 

'^  Konnedv.  Dublin  Quni'tcrlv  JoiinuU,  Feh.  IHGI 


810  MEDICAL   DIAGNOSIS. 

The  urine  is  generally  high-colored  at  first,  and  deposits  an  abun- 
dance of  urates  and  phosphates.  There  is  an  absence  of  the  chlo- 
rides, or  they  are  reduced  to  a  trace.  The  urea,  as  ascertained  by 
Parkes  ^  in  a  case  in  which  no  medicine  was  given,  is  increased ;  dur- 
ing convalescence  it  sinks  below  the  normal  standard.  In  eight  out 
of  twenty-one  cases  that  I  examined  during  an  epidemic,^  the  urine 
contained  albumin,  but  this  ingredient  was  present  only  in  the  severer 
cases.  Tube-casts,  either  finely  granular  or  hyaline,  or  epithelial,  are 
also  found. 

There  is  usually  no  Widal  reaction  in  typhus  fever.  Harvey  Lit- 
tlejohn  and  Ker  found  it  only  twice  in  twenty  cases,  and  it  was  not 
certain  whether  the  two  cases  had  not  had  previous  attacks  of  typhoid 
fever,^  Cleemann  *  reports  the  Widal  reaction  as  present  in  one  case 
of  typhus  fever  confirmed  by  autopsy. 

The  complications  encountered  during  the  course  of  the  fever,  or 
during  convalescence,  are  much  the  same  as  those  of  typhoid  fever, 
although  they  do  not  in  the  two  diseases  occur  with  equal  frequency. 
We  meet  with  abscesses,  with  large  sloughs  on  the  trunk  and  extremi- 
ties, or  with  gangrene  of  the  extremities,  with  milk-leg,  with  ery- 
sipelas, with  inflammation  of  the  parotid  gland,  with  oedema  of  the 
glottis,  and  with  pulmonary  complaints.  The  latter  are  very  common, 
and  mostly  very  alarming.  Sometimes  they  consist  merely  in  affec- 
tions of  the  larger  or  the  smaller  bronchial  tubes,  and  rales  of  varying 
size  are  heard  all  over  the  chest.  At  times,  instead  of  these  signs,  or 
associated  with  them,  may  be  noticed  dulness  on  percussion  and 
bronchial  respiration  over  the  lower  lobes  of  the  lungs,  depending 
upon  congestion,  with  consolidation,  more  or  less  perfect,  of  the  pul- 
monary tissue.  Here  is  one  of  the  worst  of  all  the  compKcations, — 
a  low  form  of  pneumonia,  often  of  the  broncho-pneumonic  type. 
During  the  last  stages  of  typhus  fever,  or  after  convalescence  has  set 
in,  acute  tuberculosis  occasionally  develops  in  the  lungs,  with  the  same 
symptoms  as  during  or  subsequent  to  typhoid  fever. 

To  discuss  now  the  differential  diagnosis  of  typhus  fever.  We 
find  various  maladies  resembling  it,  but  none  so  closely  as  typhoid 
fever.  The  subjoined  table  shows  both  their  similarities  and  their 
differences : 


^  The  Urine  in  Disease,  p.  258. 

^  Amer.  Journ.  Med.  Sci.,  Jan.  1866. 

■^  Edinburgh  Med.  Journ.,  July,  1899. 

*  Transactions  of  the  College  of  Physicians  of  Philadelphia,  Nov.  1899. 


FEVERS. 


811 


Typhoid. 

Age  generally  from  eighteen  to  thirty- 
five. 

Not  contagious  ;  mostly  sporadic. 

Attack  generally  insidious. 

Duration  fully  three  weeks  ;  frequently 
much  longer. 

Death  hardly  ever  before  end  of  second 
w^eek ;  more  generally  in,  or  after, 
third  week. 

Cerebral  symptoms  come  on  gradually  ; 
last  lonarer. 


Great  emaciation. 

Face  pale,  or  flush  confined  to  cheeks. 

Characteristic  temperature-record,  chiefly 
influenced  by  the  changes  in  the  in- 
testinal glandular  lesion. 

Abdominal  symptoms,  such  as  diarrhoea, 
tympanites  ;  stools  contain  character- 
istic bacilli  ;  intestinal  hemorrhage  not 
unusual. 

Epistaxis  common. 

Bronchitis  aud  pleurisy  ;  pulmonary  con- 
gestion. 

Eruption  light  red  in  fine  spots,  and  not 
on  extremities  or  face. 

Widal  test  positive. 


Typhus. 

At  all  ages  ;  often  in  persons  beyond 
middle  life. 

Highly  contagious  ;  usually  epidemic. 

Attack  generally  sudden. 

Duration  somewhat  shorter ;  often  not 
prolonged  beyond  second  week. 

Death  not  infrequently  at  end  of  first 
week,  and  often  before  conclusion  of 
second. 

Delirium  or  decided  stupor  comes  on 
soon,  sometimes  almost  from  the  on- 
set ;  headache  has  appeared  and  dis- 
appeared by  about  the  tenth  day. 

Less  emaciation  ;  greater  prostration. 

Face  deeply  flushed  ;  eye  injected. 

Temperature-record  more  that  of  a  con- 
tinuous fever  ;  for  the  most  part  sud- 
den and  rapid  defervescence. 

No  abdominal  symptoms  ;  bowels  con- 
stipated ;  meteorism  rare  ;  intestinal 
hemorrhage  of  extreme  rarity  ;  some- 
times acute  dysentery  during  conva- 
lescence or  as  a  sequel. 

No  epistaxis. 

Intense  pulmonary  congestion  ;  broncho- 
pneumonia. 

Eruption  darker  in  color,  coarser,  and 
all  over  body  ;  seldom  on  face. 

Widal  test  generally  negative. 


Yet  it  is  occasionally  very  difficult  to  come  to  a  conclusion  between 
typhoid  and  typhus  fever,  on  account  of  the  measly  rash  that  the 
former  exceptionally  presents  ;  or  the  symptoms  of  the  two  diseases 
are  strangely  blended  or  interchanged.  Thus,  we  may  have  consti- 
pation in  typhoid,  and  diarrhcea  in  typhus,  or  the  eruption  may  be 
curiously  mixed.     For  instance  : 

A  boy,  sixteen  years  of  age,  was  received  into  the  Philadelphia 
Hospital,  with  evident  signs  of  a  beginning  fever  of  a  low  type.  A 
day  or  two  after  his  admission,  and  corresponding,  as  nearly  as  could 
be  ascertained,  to  the  fifth  day  of  the  disease,  an  eruption  showed 
itself  all  over  the  body.  It  was  dark-colored,  petechial  in  its  aspect, 
and  did  not  disappear  on  pressure.  Associated  with  it  were  drowsi- 
ness and  constipation.  In  a  few  days  more,  however,  the  symptoms 
changed.  The  dark  eruption  faded,  and  rose-colored  spots  were  per- 
ceptible on  the  chest  and  abdomen  ;  diarrhcea  set  in,  and  the  fever 


812  MEDICAL   DIAGNOSIS. 

ran  its  course  to  a  favorable  termination  with  the  character  of  typhoid, 
just  as  at  the  onset  it  had  assumed  the  character  of  typhus. 

Besides  typhoid  fever,  typhus  may  be  confounded  with  meningitis, 
with  inflammation  of  the  lungs,  with  measles,  with  smallpox,  and 
with  the  plague.  The  distinctive  marks  between  the  lirst  two  and 
typhus  fever  have  been  rendered  apparent  while  discussing  the  cere- 
bral and  pulmonary  complications  of  the  malady.  I  shall  here  only 
dwell  again  upon  the  great  value  of  the  eruption  from  a  diagnostic 
point  of  view.  The  symptoms  that  approximate  measles,  smallpox, 
yellow  fever,  cerebro-spinal  fever,  and  the  plague  to  typhus  will  be 
analyzed  in  connection  with  these  affections. 

Oerebro-Spinal  Fever. — This  disease  is  also  known  as  cerebro- 
spinal typhus,  as  epidemic  meningitis,  and  as  epidemic  cerebro-spinal 
meningitis,  and  is  the  affection  which  has  been  called  in  this  country 
spotted  fever.  It  was  formerly  very  prevalent  in  portions  of  the 
United  States,  but  the  present  generation  of  physicians  had  little 
knowledge  of  it  until  about  simultaneously  with  the  severe  epidemic 
in  Germany  in  1863  and  1864  it  invaded  this  country  and  committed 
great  ravages,  especially  in  some  of  the  New-England  States,  in  New 
York,  and  in  Pennsylvania.  Since  that  time  it  has  become  naturalized 
here,  as  Ziemssen  states  to  be  also  the  case  in  Germany.^  There  was 
an  epidemic  in  Boston  in  1897  and  1898,  and  I  saw  a  number  of  cases 
in  Philadelphia  in  the  early  spring  of  1899. 

Cerebro-spinal  meningitis  does  not  always  present  exactly  the 
same  symptoms.  These  vary  somewhat  according  to  the  structures 
which  bear  the  brunt  of  the  disease.  Usually,  however,  marked 
cerebro-spinal  phenomena  preponderate ;  in  some  instances  the  evi- 
dences of  pulmonary  embarrassment  or  of  blood  deterioration  are 
very  prominent.  Again,  the  signs  of  spinal  disturbance  may  prevail 
over  those  of  the  cerebral,  or  the  reverse. 

The  disease  may  be  gradual  in  its  approach,  feelings  of  chilliness, 
succeeded  by  headache,  by  tenderness  at  the  nape  of  the  neck,  by 
nausea,  and  by  pain  in  the  back  and  joints,  preceding  its  full  devel- 
opment. Generally  its  onset  is  sudden ;  a  violent  chill  is  quickly 
followed  by  intense  headache,  vomiting,  and  extreme  prostration. 
However  the  beginning,  the  disease  usually  soon  reaches  its  full  devel- 
opment. The  excruciating  headache  is  associated  with  vertigo,  and 
often  with  delirium  and  stupor.  The  headache  may  remit,  but  does 
not  cease  during  the  attack.  Another  symptom  of  the  fully  developed 
disease  is  stiffness  of  the  deep  muscles  of  the  neck,  so  that  the  patient 

1  Cyclopaedia  of  the  Practice  of  Medicine,  vol.  ii.,  1875. 


FEVERS.  813 

cannot  bend  the  head  forward ;  and  the  stiffness  may  pass  into 
marked  contraction,  and  the  head  be  thrown  backward  and  rigidly 
fixed.  The  contraction  of  the  muscles  may  extend  along  the  spine, 
Avhich  frequently  is  painful,  not  specially  to  the  touch,  but  on  move- 
ment of  any  kind ;  sometimes,  moreover,  severe  spontaneous  pain 
occurs.  There  are  also  pain  at  the  nape  of  the  neck,  and  in  the  loins 
and  shooting  to  the  lower  extremities,  and  pain  at  the  epigastrium, 
and  a  feeling  of  contraction  of  the  chest.  The  Kernig  sign  of  menin- 
gitis is  always  present.  The  face  has  a  fixed  or  suffering  expression  ; 
the  patient  is  extremely  restless  ;  he  trembles  ;  talks  incoherently ; 
when  spoken  to,  does  not  appear  to  hear ;  his  pupils  are  contracted 
or  dilated  and  often  unequal,  and  there  may  be  dimness  of  sight,  or 
double  vision  and  strabismus.  The  skin  is  dry,  generally  very  sensi- 
tive, or  in  some  parts  the  sensibility  is  increased,  in  others  diminished, 
and  the  cutaneous  surface  is  frequently  spotted  with  a  red  eruption, 
erythematous  and  roseolous, — an  eruption  which  often  becomes 
brownish,  and  then  for  the  most  part  rapidly  petechial,  and  is  wholly 
uninfluenced  by  pressure  ;  or  the  purple  spots  may  be  seen  from  the 
start.  Vesicles,  too,  commonly  appear  on  the  lips.  They  show  them- 
selves from  the  third  to  the  sixth  day  of  the  disease,  while  the  erup- 
tion is  seen  on  the  first  day,  or  may  at  all  events  be  detected  by  the 
third  day.  The  blood  rapidly  undergoes  changes.  I  have  found 
marked  blood-murmurs  in  the  heart  in  a  case  of  but  two  days' 
duration. 

The  pulse  at  first  is  natural  or  slow ;  but  it  becomes  rather  fre- 
quent and  irregular,  and  commonly  remains  accelerated  throughout 
the  disease,  showing  extraordinary  variations  in  a  few  hours*;  the 
impulse  of  the  heart  is  at  times  much  augmented.  The  tongue  is 
moist  or  dry,  and  brown ;  the  breathing  often  hurried  and  shallow ; 
and  the  urine  I  have  often  noticed  to  contain  large  quantities  of  urates 
and  to  be  slightly  albuminous  ;  hyaline  and  granular  tube-casts  are 
also  found  in  severe  cases ;  in  the  malignant  cases  there  may  be 
hsematuria.  The  bowels  are  at  the  outset  constipated ;  but  as  the 
malady  advances  they  may  become  relaxed ;  in  some  cases  dysentery 
has  been  observed.  There  are  usually  persistent  irritability  of  the 
stomach,  with  great  thirst,  and  s]3asmodic  contractions  or  convulsive 
movements  in  the  muscles  of  the  extremities.  The  spleen,  early  in  the 
affection,  is  apt  to  enlarge,  but  does  not  continue  tumefied.  With 
these  symptoms,  to  which  those  of  exhaustion  become  plainly  added, 
the  disorder  progresses  to  its  close,  presenting  now  and  then  strange 
and  delusive  remissions,  soon  followed  by  distinct  exacerbations.  In 
fortunate  instances  the  morbid  phenomena  gradually  lose  their  vio- 


814  MEDICAL   DIAGNOSIS. 

lence,  and  the  patient,  greatly  emaciated,  enters  upon  a  tedious 
convalescence. 

But  though  these  are  the  symptoms  which  frec|uently  recur  in 
epidemics,  yet  as  already  indicated,  they  cannot  always  be  taken  as 
the  standard  expression  of  the  disease.  The  temperature  is  most 
variable  ;  it  may  be  scarcely  above  the  norm,  or  may  reach  between 
106°  and  108°,  or  even  higher,  without  there  being  a  proportionate 
rise  in  the  pulse.  Irregularity  of  the  temperature  is  a  very  common 
and  significant  feature.  High  temperature  may  be  interrupted  by 
long-continued  normal  temperature,  and  sometimes  the  type  of  fever 
is  like  that  of  a  tertian  intermittent,  but  with  much  longer  paroxysms. 

In  an  epidemic  in  a  mining  centre  in  the  State  of  Maryland,  care- 
fully investigated  by  Flexner  and  Barker,^  symptoms  referable  to  the 
cranial  nerves  were  especially  observed,  particularly  loss  of  smell, 
strabismus,  nystagmus,  inequality  of  the  pupils,  photophobia,  ptosis, 
impairment  of  vision,  deafness,  rigidity  of  the  face,  trismus,  besides 
Cheyne-Stokes  breathing  and  disturbances  of  speech.  The  stra- 
bismus was  divergent,  and  in  many  cases  affected  especially  the  right 
eye.  A  considerable  number  presented  engorgement  of  the  retinal 
veins  ;  some,  optic  neuritis.  The  tendon-reflexes  were  not  uniform, 
but  were  in  many  cases  diminished.  In  addition  to  herpes  and  pur- 
puric and  petechial  spots,  a  common  form  of  cutaneous  eruption  was 
an  indistinct  purplish  mottling  of  the  surface.  Nearly  twenty  per 
cent,  of  the  cases  presented  articular  complications,  principally  effu- 
sions into  and  around  the  joints,  with  redness  and  swelling.  Well- 
marked  leucocytosis  was  a  constant  feature  at  the  height  of  the  dis- 
ease ;  the  red  blood-corpuscles  were  little,  if  at  all,  changed  in 
number,  while  the  haemoglobin  was  somewhat  diminished.  Leuco- 
cytosis was  also  observed  in  every  instance  of  the  disease  seen  by 
Osier  ^  in  an  outbreak  in  Baltimore  in  1898. 

The  duration  of  the  malady  is  very  various.  Patients  may  become 
rapidly  comatose,  and  die  within  twelve  hours,  before  any  distinctly 
febrile  action  has  begun ;  or  may  sink  in  a  few  days  ;  or,  on  the 
other  hand,  the  complaint  may  pursue  a  chronic  course,  lasting  for 
many  weeks,  and  during  this  time  deafness  and  blindness,  convul- 
sions, retention  of  urine,  and  local  palsies — though  these  are  unusual 
— may  be  prominent  phenomena. 

^  American  Journal  of  the  Medical  Sciences,  Fel?.  March,  1894.  For  a  report 
of  the  ocular  findings,  see,  also,  Randolph,  Bulletin  of  the  Johns  Hopkins  Hos- 
pital, 1893,  vol.  iv.,  No.  32,  p.  59. 

-  Cavendish  Lecture,  Phila.  Med.  Journ.,  July,  1899. 


FEVERS. 


815 


The  cause  of  epidemic  cerebro-spinal  meningitis  is  the  diplo- 
coccus  intracelkilaris  meningitidis  of  Weichselbaum,  also  called  the 
meningococcus.  It  is  often  found  in  association  with  the  pneumo- 
coccus,  and,  indeed,  the  frequent  clinical  combination  with  pneumonia 
shows  a  close  connection  between  the  two  micro-organisms. 

A  valuable  means  of  diagnosis  of  cerebro-spinal  fever  has  been 
found  in  lumbar  puncture  introduced  by  Quincke.  The  puncture  is 
best  made  between  the  second  and  third,  or  the  third  and  fourth,  lum- 
bar vertebrae  with  an  ordinary  exploratory  needle,  local  anaesthesia  by 

Fig.  77. 


■''V 
*'^ 


^■^^^^ 


'^ 


,i«^ 


-^ 


The  diplococcus  intracellularis,  obtained  from  a  lumbar  puncture  of  a  c^seof  cerebro-spinal  menin- 
gitis at  the  Pennsylvania  Hospital,  by  the  pathologist,  Dr.  Cattell. 


a  freezing  mixture  having  been  previously  produced.  After  the  needle 
has  been  passed  to  about  four  centimetres  in  children,  and  double 
this  distance  in  adults,  the  fluid  generally  comes  out  drop  by  drop, 
and  from  five  to  ten  cubic  centimetres  should  be  collected  in  a  com- 
pletely sterilized  culture-tube,  which  is  then  tightly  plugged.  The 
fluid  may  be  clear  or  turbid;  in  severe  cases  it  is  usually  turbid. 
Bacteriologically  studied,  it  is  found  to  contain  the  organisms  always 
detected  in  cerebro-spinal  fever,  and  the  earlier  in  the  case  the 
lumbar  puncture  is  made  the  greater  is  the  chance  of  finding  the 
diplococcus  intracellularis.  No  evil  effects  follow  from  lumbar  punc- 
ture. Williams  found  it  even  beneficial  to  the  patient,  an  opinion 
which  Wentworth  does  not  share,  believing  any  relief  to  be  but  for  a 


816  MEDICAL   DIAGNOSIS. 

few  hours.  Wentworfh's  method^  is  very  generally  followed,  and  was 
made  use  of  by  Councilman,  Mallory,  and  Wright  in  their  valuable 
study  of  epidemic  cerebro-spinal  meningitis.^ 

Cerebro-spinal  meningitis  attacks  children  frequently.  It  is  more 
common  in  winter  and  in  spring  than  in  summer ;  though  I  have  seen 
it  in  summer.  It  is  an  affection  familiar  to  military  surgeons  ;  it  seizes 
on  recruits  who  have  been  subjected  to  unaccustomed  fatigue  or  have 
been  huddled  together  in  unhealthy  barracks  or  camps. 

To  determine  the  diagnosis  is  ordinarily  not  difficult :  the  sudden 
onset  of  the  malady  and  its  epidemic  character  are  safeguards  against 
error.  The  protracted  cases  simulate  typhoid  fever.  They  resemble 
it  in  its  long  duration,  in  several  of  the  cerebral  symptoms,  and  in 
the  occurrence  of  an  eruption,  and  sometimes  of  diarrhoea.  They 
differ  from  it  in  the  more  abrupt  invasion,  or  rather  in  the  short  time 
in  which  the  disease  reaches  an  alarming  aspect ;  and,  in  the  early 
stages,  the  violent  headache,  the  constipation,  the  constant  vomiting, 
the  slow  or  normal  pulse,  and  the  temperature,  are  unlike  the  signs 
of  enteric  fever.  In  those  cases  in  which  an  eruption  appears,  it  is 
noticed,  at  latest,  by  the  third  or  fourth  day,  not  at  the  end  of  a 
week,  as  in  typhoid  fever ;  nor  is  the  rash,  save  in  extremely  rare 
instances,  rose-colored.  The  cerebro-spinal  form  of  both  typhoid 
and  typhus  fever  is  often  mistaken  for  cerebro-spinal  fever,  and 
there  may  be,  indeed,  much  similarity  in  the  cerebro-spinal  symp- 
toms.^ But  the  eruptions  of  these  fevers  are  of  great  diagnostic 
value,  as  is  the  enlargement  of  the  spleen,  and  they  do  not  present 
the  fixed  spinal  pain,  the  severe  muscular  twitchings,  the  great  stiff- 
ness of  the  muscles  of  the  neck  and  rigidity  of  the  muscles  of  the 
back,  the  labial  herpes,  the  irregular  temperatures  we  find  in  epi- 
demic cerebro-spinal  meningitis.  Then  the  Widal  reaction  in  typhoid 
fever,  and  the  lumbar  puncture  in  cerebro-spinal  fever,  would  give 
most  valuable  evidence. 

The  suddenness  with  which  the  morbid  phenomena  occasionally 
develop,  and  the  lulls  that  take  place  in  the  course  of  the  affection, 
may  cause  it  to  be  mistaken  for  the  cerebral  variety  of  congestive  fever. 
But  the  remissions  are  not  so  marked  as  in  this  pernicious  malady, 
nor  are  the  exacerbations  preceded  by  a  long,  violent  chill.  More- 
over, the  temperature-record  is  different,  and  congestive  fever  does 


'  Detailed  in  Mallory  and  Wright's  "Pathological  Techni({ue." 

2  Report  of  the  State  Board  of  Health  of  Massachusetts,  Boston,  1898. 

■^  As  illustrating  one  of  the  difficulties  in  diagnosis,  see  Case  XII.  of  a  series 

of  typhus  cases  published  by  me  in  the  American  Journal  of  the  Medical  Sciences, 

Jan.  1866. 


FEVERS.  817 

not  begin  with  congestive  symptoms,  but  the  first  attack  is  Kke  that  of 
an  ordinary  intermittent  or  remittent :  hence  we  have  the  history  of 
the  case  to  instruct  us.  Finally  the  detection  of  hsematozoa  in  the 
blood  establishes  the  diagnosis  of  the  malarial  affection. 

From  tetanus  cefebro-spinal  meningitis  may  be  cUstinguished  by 
its  epidemic  prevalence,  and  by  the  signs  of  mental  disturbance,  which 
are  very  slight  or  wholly  wanting  in  the  former  disorder.  Trismus  is 
common  and  early  in  tetanus  ;  very  rare  in  cerebro-spinal  fever.  Gen- 
erally, too,  the  sudden  and  painful  spasms,  aggravating  the  tetanoid 
contractions,  and  the  cognizance  of  the  exciting  cause  of  the  tetanic 
convulsions,  such  as  their  following  wounds  or  punctures,  aid  in 
interpreting  their  meaning. 

How  can  we  discriminate  between  inflammation  of  the  meninges  of 
the  cord  and  epidemic  cerebro-spinal  meningitis  when  protracted? 
By  the  history  of  the  case,  the  mental  symptoms  of  the  cerebro- 
spinal fever,  the  eruption,  and  the  persistent  rigidity  of  the  muscles, 
rather  than  the  clonic  spasm  so  much  more  common  in  the  former 
malady. 

Tubercula?'  meningitis  is  distinguished  by  its  insidious  beginning, 
the  generally  much  more  protracted  course,  the  absence  of  eruption, 
and  usually  of  marked  stiffness  of  the  neck,  the  variations  in  the 
pulse  according  to  the  stage  of  the  malady,  the  irregular  breathing, 
and  the  history  of  a  tubercular  taint. 

Idiopathic  or  sporadic  cerebro-spinal  meningitis  is  a  very  rare  disease. 
It  runs  a  much  slower  course  than  the  epidemic  malady  generally 
does,  and  its  spinal  symptoms  are  less  marked.  But  it  cannot  be  dis- 
tinguished with  any  certainty  from  sporadic  cases  of  cerebro-spinal 
fever.  The  absence  of  an  eruption  and  of  the  striking  variations  of 
temperature  presented  by  the  latter  is  of  significance.  But  as  the 
diplococcus  intracellularis  has  been  found  in  the  sporadic  cases,^  these 
represent  the  same  disease  as  epidemic  cerebro-spinal  fever,  only  in  a 
somewhat  dissimilar  form.  It  is,  indeed,  a  question  whether  there  are 
not  yet  other  forms  due  to  this,  for  in  typical  anterior  poliomyelitis  the 
same  organism  has  been  found  by  lumbar  puncture.^ 

As  regards  the  different  forms  of  ordinary  meningitis,  the  distinc- 
tion, except  by  laying  stress  on  the  epidemic  character  of  the  disease, 
is  not  easy.  The  eruption  is  wanting  in  these,  and  the  spinal  symp- 
toms are  far  less  pronounced.  The  history  of  the  case,  too,  is  impor- 
tant, as  pointing  to  blow  or  injury,  to  syphilis,  to  extension  of  disease 

^  Still,  Journal  of  Pathology  and  Bacteriology,  vol.  v.,  1898. 
^  Schultze,  Munchener  Med.  Wochenschr.,  1899. 

51 


818  MEDICAL  DIAGNOSIS. 

from  contiguous  parts.  Most  of  the  cases  of  ordinary  meningitis  are 
pneumococcus  meningitis/  and  there  is  the  history  of  a  general 
pneumococcus  infection,  or  of  a  local  infection  from  the  ears  or  skull, 
or  of  a  pneumonia,  or  of  an  ulcerative  endocarditis,  of  which  the 
meningitis  is  a  complication.  Councilman,  Mallory,  and  Wright,^  in 
their  report,  state  that  the  differences  between  the  pneumococcus 
meningitis  and  the  epidemic  cerebro-spinal  form  is  the  absence  or 
slight  development  in  the  former  of  the  symptoms  which  point  to 
'extensive  infection  of  the  meninges,  of  the  cord  and  spinal  roots,  and 
to  extension  along  the  cranial  nerves.  In  a  doubtful  case  lumbar 
puncture  would  be  of  great  value. 

There  are  other  diseases  with  which  cerebro-spinal  meningitis  has 
been  confounded ;  for  instance,  owing  to  the  erythematous  eruption 
and  to  the  sore  throat  that  may  attend  it,  with  searlatina.  But  the 
onset  and  the  neck-symptoms  are  very  different ;  and  so  is  the  erup- 
tion ;  certainly  it  is  different  in  its  course.  Still,  as  regards  the  onset, 
we  must  bear  in  mind  that  both  may  be  ushered  in  by  convulsions. 
An  extremely  rapid  pulse  would  be  in  favor  of  scarlatina.  Cerebro- 
spinal fever  also  resembles  at  times  the  onset  of  malignant  measles^  or 
of  smallpox  with  petechial  spots  ;  but  the  catarrhal  symptoms  in  the 
one  case,  the  severe  pains  in  the  back  in  the  other,  are  unlike,  an(j 
presently  the  eruption  guides  us. 

I  have  known  more  than  once  the  disease,  on  account  of  the  con- 
gestion of  the  lungs  or  the  broncho-pneumonia  which  may  accom- 
pany it, — and  in  some  epidemics  the  lung-affection  is  very  marked, — 
to  be  mistaken  for  pneumonia.  In  truth,  the  diagnosis  is  sometimes 
far  from  easy.  The  mental  symptoms,  the  intense  headache,  the 
variations  in  the  pulse,  the  hypersesthesia,  the  vomiting,  the  stiffness 
and  retraction  of  the  muscles  of  the  neck,  the  eruption,  are  distin- 
guishing traits  of  value ;  but  when  these  important  symptoms  are  ill 
defined,  much  doubt  may  exist.  So,  too,  if  epidemic  cerebro-spinal 
fever  should  become  intercurrent  in  pneumonia.  Then,  as  already 
stated,  we  may  have  meningitis,  a  pneumococcic  meningitis,  associated 
with  pneumonia,  and  very  similar  to  epidemic  cerebro-spinal  menin- 
gitis with  pneumonia.  In  truth,  both  clinically  and  pathologically,  the 
relations  of  epidemic  cerebro-spinal  meningitis  to  pneumonia  are  very 
close,  and  sometimes  very  perplexing.  Without  taking  into  account 
the  eruption  and  the  results  of  lumbar  puncture,  a  differential  diag- 
nosis may  be  impossible. 


1  See  Netter,  Twentieth  Century  Practice,  vol.  xvi. 

"^  Report  of  the  State  Board  of  Health  of  Massachusetts,  1898,  p.  169. 


FEVERS.  819 

In  some  instances  of  cerebro-spinal  fever  there  is  great  pain,  with 
some  swelHng  of  the  joints,  and  the  disorder  is  thought  to  be  acute 
rheumatism.  But  the  head-symptoms,  the  state  of  the  muscles  of  the 
neck,  and  the  dissimilar  course  of  the  malady  soon  clear  up  the 
diagnosis. 

The  poison  may  produce  so  light  a  case  that  the  stiffness  of  the 
neck  may  be  mistaken  for  rheumatism  of  the  cervical  muscles.  There 
is,  however,  even  in  these  instances,  an  unusual  amount  of  headache, 
and  in  a  case  in  which  I  was  consulted  it  became  a  permanent  condi- 
tion for  several  years,  and  then  yielded. 

Urcemia  with  contracted  kidneys  may  give  us  most  of  the  same 
symptoms  as  cerebro-spinal  fever,  especially  headache,  vomiting,  and 
retraction  of  the  head ;  the  differentiation  will  depend  upon  the  pre- 
vious history,  the  presence  or  absence  of  febrile  phenomena  and  of 
cutaneous  eruptions,  and  an  accurate  examination  of  the  urine. 

From  the  cerebral  form  of  typhus,  the  dusky  countenance  of  the 
latter,  the  characteristic  eruption,  the  regularity  of  the  high  fever,  the 
violent  delirium,  and  the  absence  of  marked  spinal  symptoms,  distin- 
guish epidemic  cerebro-spinal  meningitis.  Most  of  the  same  symp- 
toms differentiate  it  from  the  cerebral  form  of  typhoid,  and,  in  addition, 
we  have,  as  the  case  progresses,  the  important  aid  of  the  Widal  test. 

Cerebro-spinal  fever  may,  during  an  epidemic,  complicate  other 
acute  maladies,  and  mix  its  symptoms  curiously  with  them.  With 
tli«  attack  the  difficulty  does  not  pass  off,  for  it  may  leave  want  of 
power  and  all  kinds  of  local  palsies,  besides  derangement  of  vision, 
permanent  deafness,  impaired  intelligence,  epilepsy,  persistent  head- 
ache, chronic  meningitis,  which  may  be  indeed  the  cause  of  the 
headache,  and  chronic  hydrocephalus.  In  one  instance  I  have  known 
an  extraordinary  swelling  of  the  whole  body  to  follow ;  the  skin  is 
hard,  tense,  and  greatly  thickened,  pits  very  little  on  pressure,  except 
around  the  ankles,  and  is  tightly  drawn  over  the  face ;  this  swelling 
and  thickening,  very  much  like  a  general  sclerema,  has  now  lasted 
for  upward  of  twenty  years,  and  has  been  attended  with  a  feeling  of 
numbness  in  the  skin  and  a  moderate  amount  of  anaemia.  There  is 
no  palsy  or  albuminuria ;  the  patient  suffers  little  inconvenience,  except 
from  her  size.  She  has  a  waxy  countenance,  and  looks  like  a  very  fat 
woman. 

Relapsing  Fever. — This  is  a  form  of  fever  characterized  by  its 
rapid  course  and  its  pronencss  to  relapse.  Epidemics  of  this  disease 
— and  it  occurs  only  in  epidemics — are  frequently  encountered  in  Ire- 
land and  in  Scotland,  There  was  an  epidemic  of  it  in  New  York  and 
in  Philadelphia  in  1869. 


g20  -  MEDICAL  DIAGNOSIS. 

The  disorder  is  decidedly  acute.  Its  invasion  is  sudden,  and 
marked  by  rigors,  pain  in  the  back  and  limbs,  vertigo,  severe  head- 
ache, and  nausea  and  vomiting.  Fever  is  soon  developed,  and  rises 
high,  to  from  1G4°  to  107°.  There  are  severe  muscular  pains,  partic- 
ularly in  the  muscles  of  the  extremities  ;  the  pulse  is  very  rapid ;  the 
temporal  arteries  throb  ;  the  tongue  is  covered  with  a  thick  white  fur. 
The  bowels,  as  a  rule,  are  constipated.  In  many  cases  there  is 
engorgement  of  the  liver,  with  yellowness  of  skin ;  and  in  nearly  all 
there  are  epigastric  tenderness  and  marked  enlargement  of  the  spleen. 
The  matter  ejected  from  the  stomach  is  greenish,  or  sometimes  black 
and  like  coffee-grounds.  Minute  points  of  extravasated  blood  are  not 
uncommonly  seen  upon  the  integument.  The  urine  is  scanty,  and 
contains  usually  bile-pigment,  some  albumin,  and  hyahne  casts.  On 
the  fifth  or  the  seventh  day,  though  sometimes  not  until  the  tenth,  the 
symptoms  subside  as  speedily  as  they  set  in,  a  profuse  perspiration 
prececUng  their  decided  abatement,  and  the  temperature  falls  to  the 
norm  or  even  below.  Convalescence  is  now  apt  to  be  rapid,  and 
seemingly  complete,  the  patient  being  up  and  going  about;  but  the 
apparent  return  to  health  does  not  last  long.  Orclmarily  after  a  week, 
therefore  on  the  twelfth  or  fourteenth  day  from  the  beginning,— 
sometimes  sooner,  rarely  later,— the  attack,  preceded  perhaps  by  a 
shght  rise  in  temperature  for  an  evening  or  two,  returns,  presenting 
again  the  same  signs,  and  again  terminating  by  a  critical  sweat  in  con- 
valescence. This  second  attack  may  be  short  and  mild ;  but  it  may 
be  both  longer  and  of  graver  character  than  the  first.  It  is,  at  times, 
followed  by  another,  and  yet  another,  relapse.  When  the  patient 
finally  throws  off  the  disease,  he  is  very  weak,  and  his  blood  is  much 
impoverished.  He  shows  a  tendency  to  dropsy  of  the  extremities  ; 
and  blowing  murmurs,  evidently  not  organic,  are  perceptible  while 
listening  to  the  heart.  These  murmurs,  however,  may  also  be  heard 
during  the  paroxysms.  The  patient  is  not  really  well  during  the 
intermission ;  his  spleen  remains  enlarged,  the  pulse  is  slow,  the  action 
of  the  heart  is  weak,  and  the  muscular  and  arthritic  pains  do  not 
entirely  disappear. 

Pvelapsing  fever  has  an  intimate  connection  with  destitution.  It  is 
a  contagious  but  far  from  a  fatal  disorder,  except,  perhaps,  in  the 
negro.  In  fatal  cases  death  sometimes  happens  during  the  first 
paroxysm  as  the  result  of  syncope,  of  hemorrhage  into  the  brain  or 
from  the  lungs  ;  or  it  may  occur  suddenly  during  the  intermission 
from  paralysis  of  the  heart.  But  the  most  common  termination  of 
the  cases  having  an  unfavorable  issue  is  in  consequence  of  complica- 
tions or  of  states  which  have  been  induced  by  the  malady,  such  as 


FEVERS.  821 

lobular  or  lobar  inflammation  of  the  lung,  hemorrhagic  pachymenin- 
gitis, abscess  of  the  spleen  or  of  the  kidney  leading  to  pyaemia,  Bright's 
disease,  dropsy,  chronic  diarrhoea,  parotitis,  palsies.  At  times  the 
patient  perishes  in  a  condition  similar  to  the  collapse  of  cholera, 
though  the  collapse  is  more  protracted  and  the  pulse  can  be  felt,  and 
discharges  from  the  bowels  are  by  no  means  a  constant  accompani- 
ment. The  extreme  prostration,  attended  with  great  coldness  of  the 
skin,  may  last  for  days.  It  is  more  particularly  met  with  in  the  "  bil- 
ious" or  "  bilious  typhoid"  form  of  the  malady, — a  dangerous  variety, 
in  which  severe  vomiting,  jaundice,  and  delirium  are  encountered,  and 
the  paroxysm  is  not  followed  by  a  distinct  intermission  or  remission, 
but  often  by  the  signs  of  collapse  mentioned,  in  which  ursemic  symp- 
toms have  been  more  particularly  noticed.^  The  collapse,  how^ever, 
may  happen  not  only  at  the  close  of  the  paroxysm,  but  in  the  remis- 
sion, whether  this  be  distinct  or  not,  or  in  a  subsequent  paroxysm  ; 
and  this  may  be  the  case  no  matter  what  variety  of  the  disorder  we 
have  to  deal  with,  and  whether  or  not  the  serious  symptoms  be  due 
to  uraemia. 

Yet  the  state  of  the  kidneys  and  of  the  urinary  secretion  has  com- 
monly much  to  do  with  the  graver  phenomena  of  the  malady.  Actual 
renal  disease  with  albumin  and  tube-casts  in  the  urine  was  discerned 
by  Obermeier  ^  in  two-thirds  of  his  cases.  It  was  also,  with  or  with- 
out tube-casts,  met  with  in  a  number  of  Pepper's  cases.^  The  urea 
is'  increased  and  may  be  retained,  thus  occasioning  grave  symptoms. 
Leucine  and  tyrosine  have  been  also  found. 

There  is  no  constant  obvious  lesion  in  relapsing  fever,  unless  it  be 
the  lesion  in  the  spleen.  This  organ  is  greatly  enlarged,  and  presents 
numerous  round  or  irregularly  shaped  bodies,  of  w^hite  or  yellowish- 
white  color.*  But  myriads  of  minute  organisms,  spirilla,  are  found  in 
the  blood  just  prior  to  the  outbreak  of  the  paroxysms,  and  at  its 
height.  Indeed,  since  Obermeier's  discovery  of  the  spirilla  in  re- 
lapsing fever,  there  is  no  doubt  that  they  are  the  cause  of  the  malady, 
and  their  detection  in  the  blood  makes  the  diagnosis  clear.  In  a 
single  field  of  the  microscope  we  may  see  only  a  few,  or  from  twenty 
to  thirty  spirilla. 

The  diagnosis  of  the  malady  cannot  be  made  positively  during  the 
primary  seizure.     Yet,  while  an  epidemic  prevails,  it  may  be  suspected 

^  Hermann,  Account  of  St.  Petersburg  Epidemic,  Schmidt's  Jahrb.,  No.  6,  1865. 
See  also  further  observations  in  Meissner's  article,  ibid.,  No.  2,  1870. 
2  Virchow's  Archiv,  1869,  Bd.  xlvii. 

■^  American  System  of  Medicine,  article  "Relapsing  Fever." 
*  Pasta  u,  ibid. 


822 


MEDICAL  DIAGNOSIS. 


Fig.  78. 


from  the  fierce  beginning  of  the  attack ;  from  tlie  fact  of  the  high 
fever-heat  showing  itself  m  less  than  twenty-four  hours,  and  exhibit- 
ing either  a  morning  remission  of  one 
to  two  degrees  and  the  maximum  of 
temperature  in  the  early  afternoon  or 
evening,  or  but  little  difference  between 
morning  and  evening,  until  the  rapid 
and  great  fall  which  takes  place  at  the 
crisis  ;  and  from  the  character  of  the 
gastric  symptoms.  Then  the  micro- 
scopical examination  of  the  blood  is 
of  great  miportance.  Relapsing  fever 
resembles  yellow  fever  in  its  short  du- 
ration and  in  some  of  its  manifesta- 
tions. But  there  is  this  evident  differ- 
ence :  in  yellow  fever  the  paroxysm  or 
febrile  stage  is  usually  much  shorter ; 
the  symptoms  in  the  remission  do  not 
subside  nearly  so  completely ;  this 
stage  is  a  brief  one  as  compared  with 
the'  decided  intermission  of  relapsmg 
fever ;  the  black  vomit  of  yellow  fever 
does  not  come  on  until  the  stage  of 
collapse  is  reached ;  and  this  far  more  fatal  malady  presents  lesions 
in  the  liver  and  heart  that  are  not  found  in  relapsing  fever,  while  it 
does  not  show  the  extraordinary  enlargement  of  the  spleen. 

From  typhoid  and  typhus  fevers,  relapsing  fever  may  be  distin- 
guished by  the  shorter  prodromata,  by  the  presence  of  jaundice,  by 
the  absence  of  the  characteristic  eruptions,  and  by  the  short  period 
during  which  the  symptoms  last.  Again,  critical  sweats  with  the  rapid 
cessation  of  the  fever  are  not  likely  to  be  seen  in  these  disorders, 
certainly  not  in  typhoid  fever ;  and  the  very  high  temperature,  the 
severe  muscular  and  arthritic  pains,  the  tenderness  over  the  liver  and 
the  spleen,  the  vertigo,  and  in  some  cases  the  early  collapse  without 
apparent  cause,  are  characteristic;  while,  on  the  other  hand,  delirium 
and  stupor  are  rarely  encountered  in  relapsing  fever.  After  the  re- 
lapse has  taken  place,  the  diagnosis  is  easy,  if  the  case  have  been 
watched  during  the  first  attack.  But,  should  it  not  have  been  under 
notice  before,  it  may  be  at  times  very  difficult,  without  an  examina- 
tion of  the  blood  for  spirilla,  to  say  whether  we  are  dealing  with 
relapsing  fever  or  with  a  relapse  of  typhoid  or  typhus  fever.  And 
this  difficulty  is  enhanced  by  the  want  of  uniformity  of  the  symptoms 


Spirilla  of  relapsing  fever  (from  Hey- 
denrelcli) :  a,  single  spirilluin ;  6,  star- 
shaped  bundle ;  c,  nidus  of  spirilla,  mth 
blood-corpuscles. 


FEVERS.  823 

in  the  second  onset  of  the  strangely  recurring  malady.  Another  diffi- 
culty is  presented  by  the  fact  that  relapsing  fever  may  exhaust  itself 
in  the  first  paroxysm.  But  this  is  an  unusual  occurrence,  and  the 
abortive  cases  are  light.  In  them,  too,  the  spirilla  may  be  detected 
in  the  blood. 

Yellow  Fever. — This  formidable  malady  takes  its  familiar  appel- 
lation of  yellow  fever  from  the  yellow  tinge  assumed  during  its  course 
by  the  skin.  It  is  a  distemper  met  with  in  hot  climates  in  low  and 
level  localities  on  the  sea-coast.  Its  source  is  unknown ;  it  is  not 
malaria,  nor  has  a  characteristic  micro-organism  as  yet  been  de- 
tected.^ All  we  know  certainly  of  the  cause  is,  that  the  malady  is 
due  to  a  specific  poison  which  does  not  exist  without  a  high  temper- 
ature, and  that  frost  is  its  greatest  enemy. 

Yellow  fever  is  an  affection  of  short  duration :  it  rarely  lasts  a 
week ;  many  die  on  the  third  or  the  fifth  day  of  the  disease.  It  has 
but  one  paroxysm,  which  is  never  repeated.  This  paroxysm  may  be 
divided  into  three  stages,  which  are  well  marked  in  some  epidemics, 
far  less  so  in  others. 

The  first  stage  is  pre-eminently  the  febrile  stage.  Its  average 
duration  is  from  thirty-six  to  forty-eight  hours,  but  it  may  last  three 
days  or  longer.  It  usually  begins  suddenly,  and  is  frequently  ushered 
in  by  a  chill.  In  rare  instances  this  is  protracted,  there  is  great 
internal  congestion,  and  death  ensues  before  reaction  occurs.  But 
much  more  generally  a  short  chill  is  followed  by  decided  fever.  The 
skin  is  harsh  and  hot ;  the  pulse  quick  and  tense,  although,  sometimes 
it  is  both  easily  compressible  and  not  much  accelerated ;  indeed,  as 
a  rule,  it  falls  before  the  temperature  declines,  and  there  is  a  marked 
disproportion  between  the  two.  On  the  evening  of  the  third  day, 
and  while  the  patient  is  still  in  the  paroxysm  of  the  fever,  there  may 
be,  as  Faget  has  pointed  out,  a  temperature  of  between  103°  and 
104°,  with  a  pulse  from  70  to  80.  The  face  is  flushed ;  the  eye  bril- 
liantly injected,  yet  watery.  The  patient  is  conscious,  restless,  anx- 
ious, and  complains  much  of  the  torturing  pains  in  his  forehead,  loins, 
and  legs  ;  the  muscles  of  the  extremities  are  sore  when  moved.  The 
breathing  is  hurried ;  the  stomach  irritable,  the  epigastrium  painful 
on  pressure ;  there  is  great  thirst.  The  bowels  are  constipated ;  the 
stools  very  dark-colored.  The  tongue  is  more  or  less  coated  and 
moist ;  sometimes  it  is  red,  while  at  other  times  it  remains  natural 

^  The  bacillus  ibund  by  Sternberg  and  called  by  hiin  bacillus  X  is  most  likely 
the  specific  agent.  It  is  very  similar  to  the  one  described  by  Sanarelli  as  the 
bacillus  icteroides.     But  our  knowledge  is  as  yet  not  positive. 


824  MEDICAL  DIAGNOSIS. 

throughout  the  disease.  There  is  albuminuria,  which,  indeed,  as 
Guiteras  mentions,  may  be  sometimes  detected  in  the  evening  of  the 
first  day,  and  is  almost  always  found  by  the  third.  The  febrile  signs 
increase  towards  evening  and  lessen  towards  morning,  but  do  not 
distinctly  remit  until  after  from  thirty-six  to  forty-eight  hours,  or  a  day 
or  two  later,  when  a  remission  does  occur,  or  when,  to  speak  more 
correctly,  the  whole  aspect  of  the  case  changes. 

The  disorder  now  appears  in  its  second  stage,  that  of  calm;  the 
fever  subsides ;  the  pulse  falls  and  becomes  easily  compressible ;  the 
headache  is  relieved  ;  the  breathing  is  no  longer  oppressed ;  the  tem- 
perature declines  to  a  little  above  the  norm.  But  the  gastric  irrita- 
bility does  not  wholly  disappear,  and  a  deep  yellow  or  orange  hue, 
which  may  have  shown  itself  slightly  almost  from  the  beginning,  gradu- 
ally tinges  the  eye  and  the  whole  surface  of  the  body.  The  patient  is 
cheerful,  and  wishes  to  get  out  of  bed.  His  sufferings  may  be,  indeed, 
over ;  convalescence  may  have  set  in  :  after  a  few  dark,  biliary  stools, 
the  yellowness  of  the  skin  fades,  and  he  slowly  gets  well. 

But  it  is  not  often  that  the  disease  relaxes  its  hold  so  easily :  more 
generally  the  deceptive  improvement  does  not  last  a  day,  and  after  a 
brief  lull  the  struggle  for  life  begins.  The  patient  grows  again  very 
uncomfortable  and  anxious,  the  fever  rises  ;  this  secondary  fever  may 
last  from  one  to  three  days,  in  favorable  cases  passing  off  gradually. 
But  in  severer  cases,  during  its  course,  the  symptoms  of  the  first 
stage  reappear  with  increased  intensity.  New  signs,  of  the  gravest 
import,  show  themselves ;  some  of  which  are  clearly  due  to  the  cor- 
ruption of  the  blood  that  the  poison  has  silently  effected.  The  pulse 
sinks,  and  becomes  slow  and  extremely  irregular  and  compressible ; 
the  skin  is  cool,  dry,  dark,  and  in  some  cases  of  a  bronze  hue,  or 
livid,  and  spots  may  be  occasionally  seen  on  its  surface.  The  stomach 
is  as  irritable  as  before,  but  the  act  of  vomiting  is  easier ;  and,  with- 
out much  retching,  large  quantities  of  altered  blood,  or  "black 
vomit,"  are  ejected.  Blood  oozes  from  the  mouth,  from  the  gums  ; 
sometimes  from  the  eyes  and  nostrils,  from  the  bowels,  and  from  the 
vagina ;  ^  or  hemorrhage  takes  place  into  internal  cavities,  and  the 
blood  is  retained.^ 

The  phenomena  of  collapse  become  now  more  and  more  unmis- 
takable :  the  black  vomit  often  ceases,  because  the  contractile  power 


^  Cases  in  the  epidemic  of  1856-57  at  Lisbon,  reported  upon  by  Lyons,  Lon- 
don, 1858  ;  also  by  Alvarenga,  Fievre  jaune  a  Lisbonne,  Paris,  1861. 

.  '^  In  a  case  at  the  Pennsylvania  Hospital  the  pericardium  was  filled  with  l)lood 
resembling  black  vomit. 


FEVERS. 


825 


Fig.  79. 


of  the  stomach  has  ceased  ;  a  low,  muttering  delirium  sets  in  ;  at 
times  uraemic  symptoms  show  themselves.  Yet  the  mind  may  remain 
clear  almost  to  the  last,  and  the  strength  be  but  little  impaired. 
Should  reaction  take  place,  recovery  is  only  very  gradual. 

But  yellow  fever  does  not  at  all  times  and  in  all  localities  present 
precisely  the  same  degree  of  intensity  or  the  same  group  of  symp- 
toms. Sometimes  it  exhibits  frank,  active  febrile  phenomena ;  at 
other  times  there  is  little  febrile  excitement,  but  a  disposition  to  inter- 
nal congestions  and  to  early  prostration.  This  congestive  form  is  far 
more  dangerous  than  the  inflammatory.  Yet  both  are  highly  destruc- 
tive. From  10  up  to  75  per  cent, 
are  the  figures  representing  the 
mortality  of  this  fearful  malady. 
Omitting  the  instances  of  an  ex- 
ceptionally mild  type,  the  aver- 
age is  calculated,  in  the  elabo- 
rate work  of  La  Roche,^  to  be  1 
in  2.32.  The  more  rapidly  the 
stages  succeed  one  another, 
the  more  dangerous  the  case. 
The  occurrence  of  black  vomit, 
of  great  epigastric  tenderness, 
of  hiccough,  of  suppression  of 
urine,  of  delirium,  of  early 
marked  jaundice,  of  oppression 
in  breathing,  of  convulsions,  of 
a  fiery,  glistening  eye,  and  of 
petechise,  warrants  an  unfa- 
vorable prognosis.  "  Walking 
cases,"  or  those  in  which  the 
patients  walk  about  until  they 
suddenly  eject  black  vomit,  al- 
ways terminate  fatally. 

As  regards  the  temperature 
in  yellow  fever,  the  maximum 
elevation  is  attained  upon  the 
first,  second,  and  third  days 
of   the   disease,   ranging    from 

102°  to  110°  ;  it  then  falls  in  the  stage  of  calm,  to  rise  usually 
again   in   the   stage   of  secondary   fever  and   of  collapse,  though  it 


Temperature  of  yellow  fever  in  a  case  ending  in 
recovery  recorded  by  Bemiss. 


1  Yellow  Fever.  Pliila(lel))liia,  1855. 


826  MEDICAL  DIAGNOSIS. 

never  attains  the  high  temperature  characteristic  of  the  first  stage, 
and  never  rises  so  rapidly.  The  elevated  temperature  of  the  first 
days  may,  however,  continue  with  httle  variation  until  the  sixth  day, 
when  the  remission  becomes  marked,  A  complete  remission  usually 
happens  on  the  morning  of  the  third  day,  but  may  not  occur  until 
the  fifth  or  the  ninth.  Whenever  it  takes  place,  the  speedy  defer- 
vescence is  very  characteristic.  Slight  rises  in  temperature  are  neither 
uncommon  nor  grave  after  the  marked  fall  in  the  second  stage.  But 
when  the  temperature  rises  rapidly  in  the  stage  of  calm  it  is  of  most 
serious  meaning.  In  this  stage  of  calm  the  absence  of  fever  may  be 
complete ;  but  generally  the  defervescence  is  only  partial :  a  remis- 
sion, therefore,  rather  than  an  intermission,^ 

Yellow  fever  has  rarely  any  complications.  It  may,  however,  seize 
upon  those  affected  with  other  diseases.  It  has  been  specially  noticed 
that  it  is  frequently  intercurrent  in  surgical  and  obstetrical  cases,^ 

The  recognition  of  yellow  fever  is,  generally  speaking,  easy.  The 
intense  pain  in  the  back,  limbs,  and  forehead ;  the  look  of  the  face ; 
the  appearance  of  the  eye ;  the  color  of  the  skin ;  the  short  duration 
of  the  high  fever ;  the  falling  of  the  pulse  while  the  temperature 
remains  elevated ;  the  nausea ;  the  epigastric  tenderness ;  the  early 
albuminuria. — constitute  a  group  of  symptoms  which  unmistakably 
mark  the  disease. 

But  let  us  look  at  the  points  of  contrast  which  yellow  fever  pre- 
sents to  other  affections.  It  differs  from  plague  by  the  absence  of 
buboes  and  of  carbuncles,  and  by  the  much  more  frequent  occur- 
rence, on  the  other  hand,  of  jaundice  and  black  vomit.  Then,  too, 
the  red,  suffused  eye  and  the  single  paroxysm  are  not  witnessed  in 
plague.  The  lines  of  demarcation  between  the  ordinary  forms  of 
continued  fever  and  yellow  fever  are  broadly  drawn.  It  is  distin- 
guished from  relapsing  fever  by  the  different  countenance,  by  the  su- 
praorbital pain,  by  the  early  remission,  and,  above  all,  by  the  extreme 
rarity  of  a  relapse  and  the  infinitely  greater  mortality.  To  typhoid 
fever  it  bears  so  slight  a  resemblance  that  it  is  scarcely  possible  to 
confound  the  two  affections ;    one,  a  short,  severe  disease,  with  its 

^  See  on  the  temperature  and  other  symptoms  Faget,  New  Orleans  Med.  and 
Surg.  Journ.,  1873-74;  Bemiss,  Amer.  Journ.  Med.  Sci.,  April,  1880,  and  article 
' '  Yellow  Fever' '  in  Syst.  of  Pract.  Med.  by  American  Authors  ;  the  temperature 
charts  of  Naegeli,  of  Rio  Janeiro,  as  given  by  Jaccoud,  Pathologie  interne ; 
Guiteras,  article  "Yellow  Fever"  in  Keating's  "  Cycloptedia  of  Diseases  of 
Children' '  and  elsewhere ;  Sternberg,  article  ' '  Yellow  Fever' '  in  Loomis  and 
Thompson's  System  of  Practical  Medicine,  1897,  vol.  i, 

^  S.  M.  Bemiss,  Clinical  Study  of  Yellow  Fever,  loe.  cit. 


FEVERS.  827 

peculiar  physiognomy  and  gastric  symptoms ;  the  other,  a  long- 
continued  malady,  of  low  type,  with  its  characteristic  eruption  and 
enteric  signs.  It  is  only  when  yellow  fever  is  protracted  beyond  the 
ninth  day  that  the  diagnosis  is  rendered  doubtful ;  and  then  we  have 
generally  the  history  to  guide  to  a  correct  understanding.  The  like- 
ness between  yellow  fever  and  tyjjhus  is  much  closer.  But  one  is  a 
short  fever,  with  distinct  stages  ;  the  other  is  a  longer,  much  more 
continued  fever.  One  has  no  marked  cerebral  symptoms ;  in  the 
other  the  cerebral  symptoms  are  the  most  prominent  feature.  One 
has  but  rarely  an  eruption,  but  often  hemorrhages ;  the  other  has 
always  an  eruption,  and  hardly  ever  hemorrhages. 

The  disease  most  likely  to  be  confounded  with  yellow  fever  is 
remittent  fever.  In  truth,  the  symptoms  are  very  similar,  and  many  of 
them  differ  only  in  intensity.  The  diagnosis  of  the  milder  forms  of 
yellow  fever  from  remittent  fever  is,  indeed,  extremely  difficult,  unless 
the  epidemic  influences  prevailing  be  taken  into  account.  Then,  as  is 
Avell  known,  the  affections  may  be  blended,  and  yellow  fever  become 
obviously  periodical  in  its  febrile  phenomena.  If  there  be  coexisting 
malaria,  we  may  find  the  malarial  parasites  in  the  blood,  and  we  are 
thus  deprived  of  the  most  positive  means  of  distinction  between  the 
two  diseases.  Under  ordinary  circumstances,  the  detection  of  these, 
and  they  are  generally  of  the  sestivo-autumnal  form,  is  of  the  greatest 
value  in  diagnosis.  The  occurrence  of  black  vomit  is  not  in  itself  a 
distinctive  sign  in  yellow  fever,  for  black  vomit  may  be  absent  in 
yellow  fever,  and,  on  the  other  hand,  it  may,  although  it  rarely  does, 
occur  in  remittent  fever,  just  as  it  has  been  known  to  occur  in  child- 
bed fever,  in  the  plague,  and  even  in  typhus.^  A  valuable  sign  is 
derived  from  an  examination  of  the  urine ;  there  is  early  and  marked 
albuminuria  in  yellow  fever. 

When  yellow  fever  is  well  marked,  it  differs  in  this  way  from 
bilious  remittent : 

Yellow  Fever.  Remittent  Fever. 

Of  short  duration,  ending  commonly  in  Lasts  nine  days  or  upward. 

from  three  to  seven  days. 

Period  of  incubation  from  five  to  nine  Period  of  incubation  very  variable  ;  may 

days.                                                       -  extend  to  months. 

^  This  statement  with  reference  to  typhus  fever  is  made  on  the  authority  of 
Stokes.  The  occasional  occurrence  of  black  vomit  in  remittent  fever  is  admitted 
by  many  others.  Some  winters  ago,  a  physician  of  this  city  brought  to  me,  for 
examination,  a  specimen  of  black  vomit  which  had  the  same  microscopical  char- 
acters that  I  have  repeatedly  found  in  the  black  vomit  of  yellow  fever.  The  patient 
undoubtedly  had  remittent  fever,  from  which  he  recovered. 


828 


MEDICAL   DIAGNOSIS. 


Yellow  Fever. 
A  disease  of  one  paroxysm,  terminating 

in  recovery  or  collapse. 
Very     severe     nausea     and     vomiting 

throughout  ;  early  jaundice  ;  early  and 

decided    epigastric   tenderness  ;    black 

vomit. 

Hemorrhages  from  gums  and  various 
parts  of  the  body. 

Tongue  clean,  or  but  slightly  coated ; 
pulse  very  variable,  frequently  be- 
comes slow,  out  of  proportion  to  tem- 
perature. 

Highly  injected,  humid  eyes  ;  often  fierce 
or  anxious  expression  of  face. 

Supraorbital  pain,  and  pain  in  back  and 
in  calves  of  the  legs. 

Very  rarely  delirium ;  mind  usually 
clear. 

Urine  acid,  very  generally  contains  albu- 
min, also  epithelial  and  granular  casts 
and  blood-casts  ;  suppression  of  urine 
common ;  no  micro-organism  in 
blood  ;  haemoglobin  in  blood-serum. 

Little  muscular  prostration  ;  often  rapid 
convalescence  ;  no  sequelae. 

Almost  certain  immunity  after  one  at- 
tack. 

Very  high  mortality  ;  disease  is  epidemic. 

Treatment  unsatisfactory. 

Autopsy  shows  inflammation  or  great 
congestion  of  stomach,  and  some  soft- 
ening. Spleen  slightly  or  not  at  all 
enlarged.  Liver  of  a  yellowish  color, 
its  secreting  cells  filled  with  oil-glob- 
ules. Kidneys  swollen,  inflamed. 
Heart  often  exhibits  granular  or  fatty 
disintegration  of  muscular  fibres. 


Remittent  Fever. 

A  disease  of  several  paroxysms,  with 
intervening  remissions. 

Nausea  and  vomiting  not  so  severe,  and 
rarely  as  marked  at  the  onset ;  neither 
as  early  nor  as  constant ;  jaundice  and 
epigastric  tenderness ;  vomiting  of 
bile. 

No  hemorrhagic  tendency. 

Tongue  heavily  coated  ;  pulse  varies  less, 
is  always  rapid  until  convalescence 
sets  in. 

Eye  not  peculiar  ;  different  physiognomy. 

Headache ;    sense    of  fulness    in   head ; 

often  no  pain  in  loins  or  in  legs. 
Delirium  frequent ;  mind  always  dull. 

No  albumin  in  urine ;  suppression  of 
urine  rare  ;  malarial  parasites  in 
blood. 


Much  greater  muscular  prostration  ;  slow 
convalescence  and  tedious  sequelae. 

One  attack  seems  rather  to  predispose  to 
others. 

Slight  mortality  ;  disease  more  endemic 
in  its  nature. 

Very  amenable  to  treatment. 

Autopsy  shows  congestion  of  stomach ; 
more  rarely  inflammation.  Markedly 
enlarged  spleen.  Liver  of  an  olive  or 
bronze  hue,  not  fatty ;  accumulation 
of  animal  starch  in  liver  of  malarial 
fever,  no  grape-sugar.^  Kidneys  un- 
changed, or  simply  congested. 


The  diagnosis  from  dengue^  at  times  a  very  difficult  one,  will  be 
considered  with  this  disease. 

Dengue. — This  is  an  •  arthritic  fever  with  a  cutaneous  eruption. 
It  is  prevalent  in  the  form  of  epidemics  chiefly  in  India,  and  in  the 
West  Indies,  in  Virginia,  South  Carolina,  Texas,  and  other  of  the 
Southern  States.     We  owe  some  of  its  best  descriptions  to  Dickson. 


^  Joseph  Jones,  Medical  and  Surgical  Memoirs,  vol.  ii.,  New  Orleans,  1887. 


FEVERS.  829 

It  has  a  period  of  inciibation  of  from  three  to  five  days.  It  usu- 
ally begins  with  pain,  stiffness,  and  swelling  of  some  of  the  smaller 
joints,  or  with  severe  muscular  pains,  aching  in  the  back,  and  stiffness 
of  the  muscles  of  the  neck.  Fever  follows,  with  suffusion  of  the  face, 
violent  headache,  hurried  breathing,  and  coated  tongue  ;  but,  as  a 
rule,  without  nausea  and  vomiting.  The  temperature  usually  attains 
its  height,  which  may  be  106°  or  107°,  within  the  first  twenty-four 
hours,  and  then  shows  during  defervescence  marked  remissions  and 
exacerbations.  On  the  third  day  the  fever  ceases  altogether  or  sub- 
sides markedly,  though  the  muscular  and  arthritic  pains  do  not  pass 
off  entirely.  The  febrile  paroxysm  may  last  somewhat  longer, 
indeed,  five  to  seven  days,  or  only  six  to  twelve  hours.  In  any  case 
it  is  apt  to  be  succeeded  by  an  interval  of  two  to  four  days  free  from 
absolute  suffering,  though  not  from  great  debility.  Then  the  pain 
returns,  and  with  it  a  moderate  fever ;  nausea  and  vomiting  and  a 
thickly-coated  tongue,  too,  are  noticed.  This  new  phase  of  the  com- 
plaint is  generally  relieved  by  the  appearance  of  an  eruption,  which 
may  be  accompanied  by  a  slight  rise  in  temperature.  The  erup- 
tion shows  itself  on  the  fifth,  sixth,  or  seventh  day  of  the  malady, 
and,  therefore,  very  much  later  than  the  rash  of  scarlatina,  which  it 
resembles  in  hue  and  aspect.  But  not  invariably ;  for  it  may  occur 
in  patches  and  be  papular,  or  even  vesicular,  or  like  urticaria.  The 
eruption  is  attended  with  a  sense  of  burning  and  of  itching,  and  dis- 
appears after  two  or  three  days'  duration,  with  desquamation.  It  is 
much  more  pronounced  than  the  slight  and  inconstant  erythematous 
rash  of  the  period  of  invasion,  which  disappears  without  desquamation 
with  the  febrile  stage. 

With  the  occurrence  of  desquamation  following  the  marked  rash 
of  the  third  period  of  the  disease  convalescence  sets  in,  marked  by 
considerable  muscular  weakness  and  general  depression,  and  fre- 
quently with  the  rheumatic  stiffness  or  soreness  persisting  for  some 
time.  Swellings  of  the  lymphatic  glands  of  the  neck,  axilla,  and 
groin  occur  in  many  instances,  and  may  continue  during  convalescence, 
which  in  any  case  is  apt  to  be  prolonged,  and  may  be  interrupted  by  a 
relapse. 

The  cause  of  this  singular  malady — the  breakbone  fever  of  parts 
of  our  country — is  unknown.  McLaughlin  ^  has  found  in  the  blood 
micrococci  in  great  numbers,  about  one-twentieth  to  one-thirtieth  the 
diameter  of  the  red  corpuscles,  of  spherical  shape  and  red  or  purplish 
in  color. 

^  Joui-n.  Amer.  Med.  Assoc,  June  19,  1886, 


830  MEDICAL  DIAGNOSIS. 

Dengue  is  generally  a  harmless  disorder,  epidemic,  and  contagious. 
Isolated  cases  are  difficult  of  diagnosis,  but  when  the  disease  largely 
prevails  its  recognition  is  easy.  It  differs  from  rheumatism  or  gout  by 
the  significant  features  of  the  fever  and  the  eruption;  from  scarlet 
fever  by  the  different  character  and  want  of  continuity  of  the  fever, 
by  the  pains,  the  arthritic  symptoms,  and  the  polymorphous  erup- 
tion towards  the  close  ;  from  influenza  by  these,  and  chiefly  by  the 
eruption.  The  remission  may  cause  the  disease  to  be  mistaken  for 
a  malarial  fever ;  but  the  irregularity  of  the  fever  in  dengue,  the 
joint  and  muscle  pains,  the  rashes,  and  the  absence  of  hepatic  and 
splenic  enlargement  are  very  unlike.  Dengue  has  a  closer  resem- 
blance to  yellow  fever,  and  the  difficulty  of  distinction  becomes  the 
greater  because  epidemics  of  both  may  be  present  side  by  side,  and 
because  we  may  And  most  of  the  same  symptoms,  even  the  jaun- 
dice, the  albuminous  urine,  the  hemorrhages,  and  the  slow  pulse  with 
elevated  temperature.  But  all  these  signs  are  of  comparatively  infre- 
quent occurrence,  and  neither  jaundice  nor  albuminuria  is  an  early 
symptom,  as  in  yellow  fever.  Moreover,  the  single  paroxysm,  the 
tongue  with  red  edges,  the  great  irritability  of  the  stomach,  the  grave 
nervous  symptoms  are  not  met  with  in  dengue ;  and,  on  the  other 
hand,  we  miss  in  yellow  fever  the  rashes,  and  the  pains  and  swelling 
of  the  joints.  Dengue  is  not  a  serious  disease  ;  yellow  fever  is  a  very 
dangerous  one,  and  the  character  of  the  prevailing  epidemic  is  mostly 
conclusive.  But  when  they  coexist,  the  distinction  between  a  light 
case  of  the  latter  and  a  severe  case  of  the  former  may  be  very 
difficult. 

Plague. — The  plague,  also  known  as  bubonic  plague  or  the  pest, 
is  an  acute  infective  fever  accompanied  by  inflammatory  swelling  of 
the  lymphatic  glands,  and  is  due  to  a  micro-organism,  the  bacillus 
pestis,  discovered  by  Kitasato,  of  Japan.  It  is  a  disease  that  prevailed 
in  frightful  epidemics  in  the  Middle  Ages,  in  Europe  as  well  as  the 
East,  and  was  popularly  called  the  "  black  death."  Now  it  is  unknown 
in  Europe  and  this  country,  except  for  a  few  sporadic  cases  that  have 
been  imported  or  have  been  developed  in  bacteriological  laboratories, 
and  the  epidemic  at  Astrachan,  in  Russia ;  though  quite  recently  there 
have  been  some  cases  in  Portugal.  In  parts  of  Asia,  especially  of 
India  and  China,  it  is  still  prevalent. 

There  are  two  forms  in  which  plague  shows  itself, — the  severe  or 
ordinary  plague,  pestis  major,  and  a  minor  or  abortive  form.  The 
ordinary  plague  is  a  highly  contagious  malady,  and  spreads  as  an 
epidemic.  It  has  a  short  period  of  incubation,  not  more  than  one 
week.     Its  early  symptoms  are  headache,  vertigo,  and  staggering  gait ; 


FEVERS.  831 

the  face  is  pallid  and  vacant ;  the  eye  is  injected  ;  the  patient  appears 
stupefied  by  the  poison.  There  is  from  the  onset  extreme  muscular 
weakness  ;  soon  high  fever  shows  itself,  preceded  by  chilly  sensations 
or  a  chill.  The  temperature  is  high,  and  may  range  between  104° 
and  107°  ;  in  favorable  cases  it  falls  gradually.  There  is  great  thirst, 
as  well  as  burning  in  the  throat  and  stomach.  The  pulse  is  rapid, 
generally  weak ;  the  bowels  are  constipated.  There  is  stupor,  or 
coma.  The  febrile  stage  does  not  generally  exceed  five  days.  Before 
its  conclusion,  sometimes  from  the  start,  buboes  appear,  often  attended 
with  some  abatement  of  the  general  symptoms.  The  glands  are  hard 
and  painful,  and  frequently  surrounded  by  oedematous  skin  ;  their  slow 
suppuration  is  looked  upon  as  favorable.  Not  only  the  inguinal  glands, 
but  the  femoral,  the  axillary,  the  submaxillary,  and  other  lymph-glands 
may  be  attacked.  The  glandular  affection  outlasts  the  febrile  stage. 
Purpuric  spots  and  petechiee,  and  hemorrhages  from  various  parts, 
especially  from  the  lungs  and  bowels,  are  also  at  times  noticed,  as  is 
bilious  vomiting. 

The  disease,  mostly  fatal,  is  a  short  one,  generally  lasting  from 
three  to  five  days,  though  suppuration  in  the  buboes  may  keep  ill  for 
a  long  time  even  the  cases  that  recover  from  the  fever.  The  short 
duration  of  the  febrile  malady,  the  absence  of  a  characteristic  erup- 
tion, the  presence  of  buboes,  distinguish  it  from  typhus  fever.  From 
forms  of  malignant  malarial  fever,  for  which  it  has  been  sometimes 
mistaken,  it  differs  by  the  signs  of  the  affection  of  the  lymph-glands, 
the  absence  of  intermissions  or  decided  remissions  and  of  malarial 
organisms  in  the  blood ;  on  the  other  hand,  the  bacillus  of  plague  can 
be  detected  in  the  lymph-glands. 

The  minor  form,  pestis  minor^  has  but  slight  fever,  and  no  violent 
symptoms.  The  glandular  swellings  are  its  only  marked  sign.  It  is 
rather  endemic  than  epidemic,  though  it  sometimes  has  been  noticed 
to  precede  ordinary  epidemic  plague,  which,  it  is  thought,  may  develop 
from  it.  The  minor  form  of  plague  lasts  about  two  weeks  ;  it  is  very 
rarely  fatal,  and  is  supposed  not  to  be  contagious. 

Malta  Fever, — This  is  a  disease  known  also  as  the  Mediterra- 
nean fever,  "  rock  fever,"  Neapolitan  fever,  and  by  many  other  names. 
There  is  reason  to  believe  that  it  also  exists  in  Porto  Rico,  and  its 
occurrence  has  been  recently  established  in  the  United  States.^  The 
disease  is  an  infectious  fever  of  hot  climates,  due  to  a  micro-organism 

1  Case  of  Musser  and  Sailer,  Phila.  Med.  Journal,  Dec.  31,  1898.  The  case 
reported  by  A.  A.  Smith,  Trans.  Assoc.  Arner.  Phys.,  1897,  as  Levant  fever,  and 
in  which  a  non-malarial  parasite  was  lnuiid  in  the  blood,  is  also,  most  probably,  an 
illustration  of  the  disease. 


832  MEDICAL  DIAGNOSIS. 

described  by  Bruce,  the  micrococcus  Melitensis,  and  is  found  in  associa- 
tion with  bad  sewerage.  It  is  generally  met  with  in  epidemics,  in 
which  the  mortality  is  not  great,  and  which  alternate  with  typhoid 
fever.  It  mostly  begins  gradually,  with  languor,  chilliness,  weakness, 
and  muscular  pains,  but  rarely  with  a  chill  or  vomiting.  Symptoms 
of  gastric  and  intestinal  catarrh  appear  early  and  continue  throughout. 
There  is  enlargement  of  the  spleen  with  tenderness,  also  muscular 
pain  and  marked  anaemia.  The  tonsils  are  often  swollen  ;  the  bowels 
are  generally  constipated.  Palpitation  is  of  common  occurrence,  and 
hsemic  murmurs  are  heard.  Epistaxis,  bleeding  from  the  gums,  and 
haemoptysis  are  usual.  Bruce  has  proved  that  while  the  red  corpus- 
cles diminish  greatly,  the  white  corpuscles,  as  in  typhoid  fever,  remain 
in  normal  amount.  The  temperature  is  that  of  a  continued  fever, 
generally  between  102°  and  104°,  but  very  irregular.  There  is  pro- 
fuse perspiration,  also  great  restlessness,  weariness,  and  often  in- 
somnia ;  orchitis  is  not  uncommon.  After  a  week,  or  longer,  the 
symptoms  decline,  and  the  patient  appears  to  be  convalescing,  but 
in  a  few  days  a  relapse  is  apt  to  happen  with  recurrence  of  the  marked 
symptoms.  In  this  relapse  the  fever  may  assume  a  remittent  rather 
than  a  continuous  form.  These  relapses  may  be  frequently  repeated, 
and  thus  the  disease  be  a  very  protracted  one.  Late  in  the  original 
attack  or  in  the  relapse  there  are  rheumatic  pains  in  the  joints,  espe- 
cially, as  found  by  Notter,^  in  the  ankle  and  sacro-ileal  joints,  which 
become  very  tender,  and  at  times  the  seat  of  an  effusion.  Node-like 
swehings  occur  on  the  ribs  and  on  the  costal  cartilages.  It  will  be 
seen  from  this  description  that  the  disease  simulates  dengue,  but  the 
peculiar  eruptions  of  this  are  absent,  and  the  arthritic  symptoms  occur 
later,  nor  is  jaundice  present.  Moreover,  the  finding  of  the  micro- 
coccus Melitensis  is  conclusive.  There  is  a  serum  test  producing 
agglutination,  similar  to  that  obtained  in  typhoid  fever. ^ 

In  rare  and  very  protracted  cases  the  swelling  of  the  joints  may 
lead  to  the  supposition  of  a  typhoid  fever  with  arthritic  complications 
and  with  relapses.  In  such  a  case,^  in  which  Malta  fever  was  sus- 
pected, that  occurred  in  my  ward  at  the  Pennsylvania  Hospital  last 
winter,  the  blood  examination  made  by  Doctors  Kirkbride  and  Kneass 
proved  it  to  be  not  Malta  fever,  but  typhoid  fever  with  arthritic  com- 
plications. There  was  a  positive  reaction  with  the  Widal  test,  but  no 
characteristic  signs  of  Malta  fever  with  the  special  serum  test  for  this. 

^  Allbutt's  System  of  Medicine,  vol.  ii.,  article  "Malta  Fever." 

2  Wright,  The  Lancet,  March,  1897. 

'^  Philadelphia  Medical  Journal,  May  6,  1899. 


FEVEES.  833 

Glandular  Fever.— This  disease,  first  described  by  Pfeiffer,  is 
an  infectious  fever  in  children  associated  with  marked  swelling  of  the 
lymphatic  glands,  especially  those  of  the  neck.  The  fever  is  generally 
pronounced,  101°  to  103°,  but  of  short  duration;  the  swelling  of  the 
glands  persists  for  several  weeks.  Not  only  the  cervical  glands  are 
swollen,  but  frequently  also  the  axillary  and  the  inguinal  glands.  Both 
spleen  and  liver  are  mostly  enlarged ;  there  is  slight  redness  of  the 
throat.  The  fever  precedes  the  tenderness  and  swelling  of  the  glands 
by  a  day  or  two  ;  at  times  there  is  puffiness  of  the  skin  around  them, 
and  they  may  suppurate.  Nephritis  is  an  occasional  complication. 
The  disease  nearly  always  ends  favorably. 

Periodical  Fevers. 

These  fevers  are  characterized  by  the  distinct  periodicity  of  their 
phenomena  :  they  exhibit  intervals  during  which  the  patient  is  wholly 
or  nearly  free  from  febrile  disturbance  ;  they  are  all  owing  to  malaria. 
This  noxious  agent  gives  rise  to  a  group  of  fevers  ever  betraying 
their  common  origin  by  their  strong  family  resemblance:  alike  in 
occurring  in  low,  swampy  localities  ;  alike  in  most  of  their  symptoms, 
and  in  the  difficulty  of  eradication  from  the  system ;  alike  in  being 
due  to  well-recognized  micro-organisms ;  alike  in  the  secondary  le- 
sions, in  the  enlargement  of  the  spleen  and  of  the  liver,  and  in  the 
altered  condition  of  the  blood,  which  they  leave  behind  them ;  and 
also  alike  in  being  under  the  control,  absolute  and  immediate,  of  cin- 
chona and  its  various  preparations. 

Since  the  great  discovery  by  Laveran  of  the  malarial  parasite  our 
knowledge  of  all  malarial  fevers  has  become  much  clearer,  and  in- 
finitely more  exact,  and  this  shows  itself  as  much  in  diagnosis  as  in 
pathological  studies.  It  is,  therefore,  fitting  that  a  short  description 
of  the  malarial  organisms  should  precede  the  description  of  the  indi- 
vidual fevers,  at  least  in  so  far  as  they  concern  c[uestions  of  diag- 
nosis ;  for  the  larger  questions  of  origin,  growth,^  and  technical  study 
I  must  refer  to  the  admirable  works  of  Thayer  and  of  Mannaberg,^ 
and  to  the  numerous  papers  of  observers,  such  as  Marchiafava,  Celli, 
Golgi,  Grassi,  Sternberg,  Dock,  Hewetson,  and  Manson,  who  have  done 
so  much  to  extend  our  knowledge. 

The  malarial  parasite  is  best  studied  in  fresh  blood,  care  being 
taken  that  the  cover-glasses  and  slides  have  been  well  cleansed  in 
alcohol  or  ether ;  a  drop  of  blood  is  readily  obtained  from  tlie  lobe  of 

1  Malarial  Fevers,  1897. 

^  In  Nothnagel's  Spec.  Path.  u.  Therap.,  1899. 
52 


834  MEDICAL  DIAGNOSIS 

the  ear,  thoroughly  washed.  If  stains  be  employed,  Loeffter's  methy- 
lene-blue  is  very  serviceable.  There  are  three  forms  of  i^arasites  now 
recognized,  which  pass  through  their  cycle  of  development  in  from 
twenty -four  to  seventy-two  hours  ;  at  the  start  they  are  small,  color- 
less bodies  mthin  the  red  corpuscles  and  are  soon  seen  to  be  actively 
amoeboid.  As  the  bodies  increase  in  size,  pigment  granules  dot  their 
periphery  ;  gradually  the  centre  or  very  nearly  the  entire  red  corpuscle 
is  taken  up  ;  the  pigment  in  the  organism  increases,  and  becomes 
darker  and  coarser.  After  full  development  has  been  reached,  sporu- 
lation  takes  place,  and  the  pigment  mostly  collects  into  a  small  mass 
at  a  particular  point,  generally  towards  the  centre.  The  red  corpus- 
cle now  bursts  and  the  segments  or  spores  are  set  free,  and  invade 
fresh  corpuscles  ;  the  pigment  granules  float  in  the  blood-serum.  But 
the  parasite  may  escape  from  the  red  blood-cell  before  sporulation. 
In  some  instances  roundish  vacuoles  of  irregular  size,  thought  to  be 
due  to  degenerative  process,  are  observed  in  the  parasite  ;  or  thread- 
like, colorless,  actively  motile  flagella  appear  from  the  periphery  of  the 
organism. 

Different  forms  of  malarial  parasites  produce  different  types  of 
malarial  fever,  and  there  is  a  close  connection  between  their  develop- 
ment and  the  clinical  features  of  the  fever ;  the  paroxysms,  as  pointed 
out  by  Golgi,  are  associated  with  the  segmentation  of  a  group  of  the 
malarial  parasites.  Very  often  there  is  evidence  of  two  or  more 
groups,  and  if  these  reach  maturity  on  different  days  and  at  different 
times  types  of  fever  are  produced  entfrely  different  from  those  when 
the  groups  are  single.  A  combination  of  the  main  malarial  organisms 
may  also  occur. 

There  are  three  distinct  varieties  of  malarial  parasites,  and  some 
subdivisions  ;  the  three  distinct  and  chief  varieties  are  : 

1.  The  parasite  of  tertian  fever. 

2.  The  parasite  of  quartan  fever. 

3.  The  parasite  of  asstivo-autumnal  fever. 

1.  The  tertian  parasite,  by  far  the  most  frequently  observed  in  this 
country,  completes  its  cycle  of  development  in  forty-eight  hours.  It 
is  larger,  less  refractive,  has  much  more  active  amoeboid  motion  than 
the  quartan,  and  has  finer,  lighter  pigment  granules  and  rods;  the 
pigment  moves  very  markedly.  The  red  corpuscle  containing  the 
parasite  swells  up,  and  becomes  paler  than  normal.  The  pigment  at 
maturity  is  collected  into  a  mass  near  the  centre,  and  the  parasite  is 
absolutely  quiescent;  it  breaks  up  into  fifteen  to  twenty  segments, 
and  the  spores  are  rounded  and  smaller  than  those  of  the  quartan 
parasite. 


DESCRIPTION   OF   PLATE   VI. 

MALARIAL   PARASITES. 

A  number  of  these  micro-organisms  were  obtained  in  blood  examinations  of 
malarial  fevers  made  at  the  Pennsylvania  Hospital,  and  drawn  from  nature  by  Dr. 
C.  F.  M.  Leidy.  Some  of  the  rarer  forms,  especially  of  the  aestivo-autumnal  variety, 
are  taken  from  the  works  of  Mannaberg  and  of  Thayer.  The  engraving  is  by  Mr. 
Louis  Schmidt. 

In  the  tertian  group,  the  first  is  a  red  corpuscle  of  normal  size.  The  swelling 
of  the  corpuscle  by  the  tertian  parasite  is  seen  in  the  following  ones. 

The  second  and  third  show  hyaline  bodies  ;  the  next  four,  the  gradual  growth 
and  development  of  the  parasite  and  pigmentation  in  the  same  ;  then  follow  seg- 
mentation and  discharge  of  the  spores,  of  which  there  are  from  fifteen  to  twenty. 
The  last  body  is  a  large  flagellate. 

In  the  quartan  group  are  shown  different  forms  of  the  quartan  parasite,  their 
development  and  segmentation.  The  parasite  is  small  and  the  corpuscle  has  a 
tendency  to  contract  around  it,  the  rim  having  a  deep  coloration.  The  pigment 
is  coarser  and  darker  than  in  the  tertian,  and  there  are  only  from  six  to  twelve 
sporules  in  segmentation.     The  flagellate  is  smaller  than  the  tertian. 

In  the  (jestivo-autumnal  form  the  pigmentation  is  seen  to  be  more  marked  to- 
wards the  periphery  of  the  parasite.  The  figures  show  the  small  size  of  this  para- 
site, which  is  the  smallest  of  the  malarial  parasites,  but  always  very  distinct.  In 
the  fourth  of  this  group  the  degeneration  of  the  corpuscle  is  distinctly  perceived. 
On  the  last  line  various  forms  of  ovals  and  crescents  are  seen  as  well  as  a  flagellate. 
The  flagellate  is  coarsely  pigmented,  but  smaller  than  the  tertian  variety. 


Plate  YI. 

malarial.  par.xsitks 

tertian  forms. 


■  t  f 


I        V 


cr^*=^ 


4 


QUARTAN    FORMS 


l> 


i#i 


JK 


fj' 


^STIVO-AUTUMNAL  FORMS. 


I"'  a.-'    1 

w 


FEVERS.  835 

2.  The  parasite  of  quartan  fever  has  a  cycle  of  development  of 
about,  seventy-two  hours ;  sporulation  occurs  every  fourth  day.  The 
pigment  is  coarse  and  dark  and  found  on  one  side  chiefly ;  the  para- 
site and  the  pigment  have  slow  motions.  The  young  parasite  is  small, 
about  one-fourth  the  size  of  a  red  blood-corpuscle.  As  the  parasite 
grows,  the  red  corpuscle  contracts  around  it,  and  the  rim  shows  deep 
coloration ;  there  is  no  irregular  breaking  up  of  the  organism  into 
sections,  of  which  there  are  from  six  to  twelve.  Before  segmentation, 
the  pigment  tends  to  the  centre  in  radial  lines,  forming  a  star-like 
arrangement.  When  two  groups  of  organisms  reach  maturity  on 
different  days  we  have  paroxysms  on  successive  days  and  a  day  of 
intermission. 

3,  The  mstwo-autumnal  parasite  is  the  most  irregular  of  all  the 
malarial  parasites ;  the  cycle  of  development  varies  from  twenty-four 
to  forty-eight  hours,  and  it  does  not,  like  the  other  forms,  occur  in 
great  groups  which  arrive  at  maturity  at  the  same  time.  Its  most 
distinctive  feature  is  the  production  of  crescents  from  the  spherical 
parasite  within  the  red  corpuscle.  These  crescents  are  very  gener- 
ally pigmented ;  but  the  bodies  may  be  oval  or  fusiform  in  place  of 
crescentic.  The  crescents  are  not  met  with  unless  the  fever  be  at 
least  of  a  week's  duration.  In  their  earliest  stages  the  sestivo- 
autumnal  organisms  are  like  the  tertian  or  quartan  forms,  except 
smaller,  and  they  often  first  show  themselves  as  minute  ring-like  re- 
fractive bodies,  in  which  a  few  dark-brown  pigment  granules  appear, 
and  the  red  corpuscles  soon  exhibit  degenerative  changes.  The  pig- 
ment gathers  towards  the  centre,  and  segmentation  takes  place  as  in 
the  tertian  parasite.  But  segmentation  is  very  rarely  seen  in  the  blood 
taken  from  the  peripheral  circulation,  indeed,  only  the  youngest  form 
of  the  parasite  and  the  crescents  are  encountered ;  the  later  develop- 
ment of  the  organism  and  the  segmented  bodies  can  be  studied  in 
blood -taken  from  the  spleen.  The  irregularity  of  development  and 
maturity  accounts  for  the  irregularity  of  the  clinical  manifestations  in 
the  malarial  fevers  in  which  the  sestivo-autumnal  parasite  is  found. 
This  is,  indeed,  pre-eminently  the  malarial  organism  of  all  irregular 
exhibitions  of  malarial  infection,  as  well  as  of  the  autumnal  malarial 
remittent  fever  which  is  so  varied  in  form.  The  parasite  has  been 
further  divided  into  two  varieties,  the  quotidian  and  malignant  tertian 
organisms,  and  these  have  been  further  subdivided  as  to  whether  pig- 
mented or  not.  But  these  distinctions  are  not  generally  accepted, 
and  their  clinical  value  has  not  been  determined. 

We  shall  now  look  at  the  clinical  side  of  malarial  fevers,  premising 
that  it  is  the  general  tendency  of  malarial  paroxysms  to  anticipate. 


836  MEDICAL  DIAGNOSIS. 

Intermittent  Fever. — The  paroxysm  comes  on  with  a  chiU :  the 
face  becomes  pale,  the  lips  bluish  ;  the  teeth  chatter ;  the  skin  is  cold ; 
there  is  a  feeling  of  mieasiness  and  fatigue.  After  a  period  varying 
commonly  from  half  an  hour  to  an  hour,  this  cold  stage  passes  off: 
Now  we  find  decided  heat  of  the  surface,  with  restlessness,  thirst,  a 
full,  rapid  pulse,  muscular  pains,  a  scanty  secretion  of  urine ;  in  other 
words,  active  febrile  symptoms.  These  continue  for  hours,  for  a 
period  always  much  longer  than  the  first  stage  :  then  a  sweat  breaks 
out  all  over  the  body ;  the  pulse  becomes  softer  and  less  frequent ; 
the  secretions  are  fully  re-established  ;  and  this  sweating  stage  termi- 
nates the  paroxysm. 

The  patient  is  now,  for  the  time  being,  well ;  but  the  disease  soon 
recurs :  in  from  twenty-four  to  seventy-two  hours  the  paroxysm  re- 
peats itself.  In  the  former  case  we  call  the  fever  a  quotidian ;  in  the 
latter,  a  quartan.  The  tertian  type  is  before  us  when  the  paroxysm 
sets  in  again  in  about  forty-eight  hours  ;  the  double  tertian,  when  we 
find  a  daily  attack,  but  those  of  alternate  days  alone  corresponding  in 
time  and  severity.  Even  a  quintan  ague  may  happen.^  The  period 
between  the  ending  of  one  attack  and  the  beginning  of  another  is 
spoken  of  as  the  intermission  or  apyrexia  ;  while  the  time  between  the 
beginning  of  the  two  paroxysms,  including  the  first  with  its  suc- 
ceeding intermission,  is  called  the  interval. 

The  tertian  and  the  quotidian  are  the  usual  types  in  this  country. 
In  the  ordinary  tertian  there  is  a  single  group  of  infection  with  the 
tertian  malarial  organism  ;  where  the  quartan  parasite  is  present  in 
large  numbers  and  as  a  single  infection  that  reaches  maturity  at  about 
the  same  time,  we  have  the  quartan  fever ;  if  in  two  groups,  reaching 
their  full  development  on  successive  days,  with  a  day  of  intermission, 
the  double  quartan.  Should  either  the  tertian  or  the  quartan  parasite 
occur,  the  first  in  double,  the  second  in  triple  infection, — the  different 
sets  of  parasites  reaching  maturity  on  successive  days, — we  have  the 
quotidian  type  of  the  fever,  which  may  thus  depend  on  either  the 
tertian  or  cjuartan  parasite ;  or,  again,  there  may  be  a  coexistence  of 
these,  which  is  not,  however,  frequent.  Even  the  Eestivo-autumnal 
infection  may  produce  quotidian  intermittents.  Yet  this  is  not  com- 
mon, and  the  paroxysms  are  much  less  regular.  The  most  usual 
cause  of  the  quotidian  in  this  country  is  the  infection  with  two 
groups  of  tertian  parasites  that  reach  maturity  on  successive  days. 

The  varied  types  of  the  fever  present  marked  differences  in  the 
character  and  duration  of  the  several  stages.     The  tertian  has  gener- 

1  Case  of  Henry,  Brit.  Med.  Jouni.,  Feb.  18,  1888. 


FEVERS. 


837 


ally  the  longest  hot  stage,  the  quartan  the  longest  cold  stage.  In  the 
quotidian  there  is  a  short  cold  stage,  followed  by  a  hot  stage  which 
may  last  for  upward  of  fifteen  hours.  Occasionally  the  stages  are 
very  irregular  and  anomalous.  Thus,  the  sweating  stage  may  precede 
the  cold  stage,  or  it  may  be  the  only  one  which  shows  itself;  or,  again, 
the  rigor  may  be  altogether  wanting.  Sometimes,  there  are  no  distinct 
stages,  but  the  patient  has  a  "  dumb  ague,"  which  manifests  itself  at 
definite  periods  by  a  feeling  of  great  depression,  or  of  a  severe  pain 
at  some  portion  of  the  body,  or  "by  chilly  sensations,  or  by  headache, 
or  by  nausea  and  vomiting,  or,  as  I  have  seen,  by  excruciating  pain 
over  the  kidneys,  and  almost  entire  sup- 
pression of  urine,  or  by  spasmodic  ob- 
struction of  the  intestine.^ 

The  temperature  in  intermittent  fever 
shows  a  record  that,  in  doubtful  cases, 
may  be  turned  to  great  advantage.  Not- 
^Adthstanding  the  marked  sense  of  chilli- 
ness, the  thermometer  rises  suddenly  and 
rapidly  to  a  high  degree ;  there  may  be  a 
slight  elevation  of  temperature  for  an  hour 
before  a  chill,  but  the  striking  rise  begins 
with  the  chill.  Even  during  the  decided 
chill  of  the  beginning  of  the  paroxysm  it 
indicates  105°  or  more  in  the  axilla.  The 
temperature  remains  stationary,  or  con- 
tinues to  rise,  though  not  much,  during 
the  hot  stage,  and  during  the  sweating 
stage  falls  at  first  slowly,  then  rapidly, 
until  it  comes  down  to  about  the  normal 
heat.  During  the  chill  the  peripheral  tem- 
perature is  decidedly  lowered ;  during  the 
hot  stage  it  is  increased.  But  with  the 
ending  of  the  paroxysm  it  is  found  that 
the  fall  has  been  rapid.  In  the  intermis- 
sion the  thermometer  in  the  axilla  marks 
a  natural  temperature,  or  one  somewhat 
lower   than    in    health.      It    rises    again 

quickly  with  each  paroxysm.     No  other  malady  presents  these  varia- 
tions. 

In  some  cases  of  intermittent  fever   an  intermitting   murmur  is 


.  9". 

.__ . : 

96- 

= 

Ti'miUTatuiv-n-cctril  oS  a  tertian 
liTiiiitti'iit. 


^  Cases  of  Hoyt,  Atlanta  Med.  and  Surg.  Journ.,  Sept.  1875. 


838  MEDICAL  DIAGNOSIS. 

heard  over  the  spleen.  This  is  ascribed  to  the  movement  of  the  blood 
in  the  splenic  arteries  with  the  systole,  in  consequence  of  the  soft, 
enlarged,  and  overfilled  condition  of  the  spleen.  It  is  usually  detected 
most  distinctly  during  the  febrile  period,  ceases  with  the  paroxysms,^ 
and  is  not  heard  in  chronic  malaria. 

To  the  peculiar  appearance  of  the  tongue  which  those  under  the 
malarial  influence  may  show,  Osborn  has  directed  particular  atten- 
tion.^ There  is  a  distinct  lateral  boundary  of  the  organ,  an  appear- 
ance of  indentation  transversely,  and  the  inferior  surface  appears  to 
have  encroached  upon  the  superior  and  lateral  borders. 

The  diagnosis  of  an  ordinary  and  regular  intermittent  is  easy. 
Leaving  the  other  malarial  fevers  out  of  consideration,  only  two 
morbid  states  are  likely  to  present  recurring  rigors  and  febrile  excite- 
ment, and  are,  therefore,  apt  to  be  confounded  with  it :  hectic  fever,  and 
chills  attending  upon  suppuration  in  deep-seated  parts.  Now,  hectie 
fever  differs  in  this  from  intermittent :  it  is  simply  a  fever  of  irrita- 
tion, the  cause  of  which  a  careful  scrutiny  will  generally  detect.  We 
find  it  accompanying  many  chronic  diseases  in  which  destruction  of 
tissue  occurs,  especially  phthisis  ;  and  the  chronic  affection  has  its 
own  signs,  which  exist  at  all  times,  whether  the  symptomatic  fever  be 
present  or  not.  Then  its  outbreaks  are  irregular.  Several  often  take 
place  within  the  twenty-four  hours  ;  their  mtermissions  are  incom- 
plete ;  the  temperature  does  not  fall  as  in  intermittent  fever,  for  there 
is  not  complete  defervescence;  and  although  the  paroxysms  may 
begin  with  chilliness,  they  are  not  ushered  in  by  a  well-defined  rigor. 
Further,  they  are  apt  to  be  morning  paroxysms,  and  are  not  modified 
by  antiperiodics.  Whenever,  indeed,  we  find  an  intermitting  fever 
not  influenced  by  these  agents,  it  ought  to  arouse  suspicion,  and  all 
the  internal  organs,  particularly  the  lungs,  should  be  carefully  explored. 
Thus  only  can  serious  errors  in  diagnosis  be  guarded  against. 

When  jjus  forms,  and  especially  when  it  forms  in  internal  cavities, 
it  betrays  its  presence  by  rigors,  followed  by  more  or  less  fever.  But 
these,  unlike  the  chills  of  ague,  do  not  repeat  themselves  at  definite 
periods.  Moreover,  in  the  midst  of  the  apparent  intermission,  febrile 
signs  or  other  manifestations  of  a  seriously  disordered  system  may  be 
discovered ;  or  we  may  find  the  local  cause,  for  instance,  a  pelvic  cellu- 
litis. The  chills  of  ordinary  pyaemia,  unlike  the  malarial  malady,  are 
often  characterized  by  the  profuse  sweating  that  immediately  follows 
them,  rather  than  by  an  active  development  of  fever.     In  cases  of 


^  Maissurianz,  St.  Petersburger  Medicin.  Wochenschr.,  1882,  12. 
^  Transactions  of  the  American  Medical  Association,  vol.  xx. 


FEVERS.  839 

purulent  collections  and  infection  we  have  marked  leucocytosis,  but 
of  even  greater  value  in  diagnosis  is  the  absence  of  the  malarial 
organisms. 

There  are  other  causes  which  may  occasion  attacks  of  fever  hap- 
pening in  paroxysms  and  simulating  ague,  though  not  malarial.  They 
may  occur  in  diseases  of  the  heart,  as  in  ulcerative  endocarditis  and  in 
valvular  affections.-^  Gall-stones  which  form  in  the  radicals  of  the 
hepatic  duct  in  the  interior  of  the  liver  may,  as  Frerichs  shows,  give 
rise  to  attacks  of  chills,  followed  by  heat  and  by  sweating,  easily  mis- 
taken for  ague.  The  fact  that  these  febrile  phenomena  are  preceded 
in  many  cases  of  intrahepatio  concretion  by  dull  pain  in  the  hepatic 
region,  and  by  sudden  sharp  seizures  of  pain  at  the  lower  part  of  the 
thorax  on  the  right  side,  is  very  significant.  Then  we  have  the  ordi- 
nary form  of  hepatic  fever,  which  we  have  already  discussed,  and  of 
which  impacted  gall-stone  is  the  most  common  cause,  and  recurring 
jaundice,  with  more  or  less  pain,  the  main  symptom.  The  paroxysms 
often  come  at  first  with  some  regularity,  and  are  more  likely  to  be 
repeated  in  the  afternoon  and  evening,  while  the  malarial  paroxysm 
more  commonly  occurs  in  the  morning. 

An  affection  which  on  account  of  the  chill  succeeded  by  fever  might 
be  mistaken  for  the  malarial  disorder  is  the  curious  so-called  urethral 
fever  which  sometimes  arises  after  the  passage  of  a  bougie,  and  which 
may  even  terminate  m  death.^  Our  knowledge  of  the  introduction  of 
the  instrument,  and  the  non-recurrence  at  a  fixed  time  of  the  rigor 
and  febrile  phenomena,  furnish  the  points  of  distinction. 

Yet  another  affection  liable  to  be  mistaken  for  intermittent  fever  is 
syphilitic  fever.  The  fever  may  occur  in  attacks  consisting  of  a  chill, 
followed  by  a  hot  stage  and  sweating,  and  be  so  similar  to  the  mala- 
rial disorder  as  to  lead  to  error.^  The  apparent  ague-fits  happen, 
however,  towards  evening,  and  are  succeeded  or  accompanied  by 
severe  headache  and  pains  in  the  bones, — in  fact,  by  the  same  symp- 
toms as  the  more  ordinary  kind  of  syphilitic  fever.  In  the  form  in 
which  the  febrile  symptoms  are  continuous,  these  generally  precede 
the  eruption  for  a  week  or  more,  and  may  continue  after  this  appears  ; 
but  an  eruption  may  be  found,  and  the  historj^  of  syphilis  be  doubt- 
ful.    In  these  obscure  cases  the  fever  lasts  a  long  time,  the  pulse-rate 

^  Osier,  Practitioner,  vol.  i..  No.  3,  p.  181  ;  Henry,  Amer.  Journ.  Med.  Sci., 
July,  1899,  has  reported  a  case  of  mitral  stenosis  with  fever  recurring  at  intervals 
of  about  a  week. 

2  Roser,  quoted  in  Brit,  and  For.  Med.-Chir.  Rev.,  Oct.  1867. 

^  See  cases  of  Bassereau,  referred  to  by  Bumstead  in  his  Treatise  on  Venereal 
Diseases  ;  Ord,  loc.  cit. 


840  MEDICAL  DIAGNOSIS. 

is  slow,  and  they  gradually  yield  to  antisyphilitic  treatment,  while  by 
repeated  examinations  of  the  blood  ansemia,  but  no  malarial  parasites, 
are  detected.^ 

We  may  also  find  syphilitic  fever  in  cerebral  syphilis  -with  symp- 
toms like  those  of  malaria.^  The  paroxysmal  pyrexias  may  be  met 
with  at  very  varying  times  after  the  infection,  though,  like  everything 
connected  with  cerebral  syphilis,  they  are  generally  late  manifesta- 
tions. There  is  often  a  preceding  history  of  severe  headache,  of 
irregular  motor  palsies  and  epileptic  attacks,  of  mental  failure  and 
perversion,  or  of  symptoms  similar  to  general  paralysis,  though  want- 
ing in  the  tremulousness.  The  aphasia  which  may  be  met  with  is 
said  to  be  commonly  associated  with  left-sided  hemiplegia. 

Syphilitic  fever  is,  on  the  whole,  less  apt  to  be  confounded  with 
malarial  disease  than  it  is  with  tubercular  affections  ;  a  very  common 
error,  as  Janeway  has  proved.^  Long-continued,  causeless  fever  in 
wliich  blood-examinations  show  no  malarial  organisms,  and  where 
there  is  no  distinct  evidence  of  tuberculosis,  should  always  make  us 
very  suspicious  of  syphilis. 

In  the  diagnosis  of  intermittent  fever  we  have  also  to  consider 
that  certain  diseases  which  are  non-malarial  exhibit  at  times  a  decep- 
tive j9e?^toc??'c% ;  they  may  be  worse  every  second  day.  Even  mania, 
as  Schroeder  van  der  Kolk  has  pointed  out,  may  take  this  type.  In  all 
such  instances  the  microscopic  examination  of  the  blood  for  malarial 
parasites  is  of  the  greatest  value. 

In  the  puerperal  state  a  malarial  outbreak  may  happen  which,  as 
Manson  and  Fordyce  Barker^  have  shown,  may  be  mistaken  for  puer- 
peral fever.  Unli\e  the  latter,  however,  the  puerperal  malarial  fever 
is  attended  with  pain  in  the  head,  back,  and  limbs,  and  does  not  gen- 
erally appear  so  soon  after  parturition, — not,  therefore,  between  the 
first  and  fifth  days  after  deliverj^  Moreover,  it  has  at  the  beginning 
a  great  temperature-rise,  and  marked  remissions  or  intermissions. 
Puerperal  malarial  fever  may  lead,  after  the  twelfth  day,  to  secondary 
hemorrhage. 

Now,  in  all  these  diseases  simulating  outbreaks  there  are  two  tests 
of  great  value,  more  important  than  any  mentioned, — one  the  thera- 
peutic test  of  their  not  yielding  to  decided  doses  of  quinine  ;  the  other, 
still  more  valuable,  that  careful  and   repeated   exammations  of  the 

^  Cases  of  Musser  and  of  Prentiss,  Phila.  Med.  Journ.,  July,  1899. 
^  Wood,  Transactions  of  the  College  of  Physicians  of  Philadelphia,  Feb.  1884  ; 
also  in  Medical  News,  Philadelphia,  March,  1881  ;  Janowsky,  quoted  ibid. 
^  Transactions  of  the  Association  of  American  Physicians,  1898. 
*  Medical  Record,  Feb.  1880  ;  Virginia  Med.  Monthly,  Nov.  1881. 


FEVERS.  841 

blood  fail  to  detect  the  malarial  organisms.  Further,  though  not  so 
generally  applicaJ3le  in  complicated  malarial  fevers,  there  is  no  leuco- 
cytosis,  while  decided  leucocytosis  is  among  the  features  of  most  of 
the  conditions  named,  and  especially  of  all  those  with  a  septic  in- 
fection. 

Remittent  Fever. — This  is  a  fever  pre-eminently  of  hot  chmates 
and  malarial  districts,  and  is  now  more  generally  described  as  aestivo- 
autumnal  fever.  It  is  the  fever  of  Hungary,  of  the  Pontine  Marshes, 
and  particularly  of  Africa  and  the  southern  portion  of  the  North 
American  continent,  and  of  parts  of  South  America.  Occasionally, 
not  often,  we  meet  with  it  in  whiter  and  in  early  spring;  very  gener- 
ally, during  the  summer  and  autumn  months.  The  malarial  parasite 
that  occasions  it  is  the  ^stivo-autumnal  parasite,  of  which,  as  above 
stated,  a  main  characteristic  is  irregularity,  and  we  see  this  reproduced 
m  the  clinical  features  of  the  disease. 

Remittent  fever  has  no  well-defined  and  constant  prodromic 
symptoms,  except,  perhaps,  a  singular  sense  of  gastric  uneasiness.  It 
is  ushered  in  by  a  marked  chill,  soon  succeeded  by  violent  fever, 
which,  after  a  varying  period,  decreases,  and  then  breaks  out  again. 
By  this  time  the  symptoms  of  the  disease  are  very  apparent.  The 
patient  complains  of  pain,  of  fulness  and  of  throbbing  in  his  head. 
He  is  restless  and  distressed ;  his  limbs  ache ;  his  tongue  has  become 
coated;  he  suffers  from  thirst,  and  rejects  the  contents  of  the  stomach. 
After  continuing  at  their  height  from  six  to  eighteen  hours,  these 
symptoms  again  suloside :  a  sweat  breaks  out  all  over  the  body ;  the 
irritability  of  the  stomach  lessens ;  the  patient  is  composed,  even 
cheerful ;  his  headache  has  nearly  ceased,  and  he  falls  into  a  quiet 
slumber.  But  this  lull  is  not  of  long  duration,  not  longer  than  some 
hours.  Soon  the  active  fever  is  rekindled  :  the  skin  is  as  hot  and  dry 
as  before,  the  pulse  as  full,  frequent,  and  hard ;  the  spleen  is  observed 
to  be  swollen  ;  and  the  other  symptoms  return  with  increased  in- 
tensity, again  to  abate,  again  to  recur,  until  either  the  exacerbations 
are  effaced  and  the  fever  assumes  a  continued  type,  or  else  the  remis- 
sions become  better  and  better  defined, — more,  indeed,  like  intermis- 
sions than  remissions.  In  the  progress  of  the  disease  and  after  its 
height  the  pulse  is  generally  quicker  and  weaker  than  at  first. 

The  temperature  rises  markedly  with  the  first  chill,  and  continues 
to  rise  during  the  high  fever  that  follows.  With  the  sweating  stage  it 
declmes  by  several  degrees,  to  rise  to  a  greater  height  than  previously 
with  the  succeeding  febrile  phenomena ;  then  again  there  is  a  fall  in 
the  remission,  with  another  quick  rise  in  the  fever,  which  may  attain 
a  very  high  point,  marking  from  105°  to  108°.     The  greatest  height 


842 


MEDICAL  DIAGNOSIS. 


is  usually  reached  in  the  exacerbation  of  the  third  day.  After  this 
the  remissions  become  less  distinct,  and  may  be,  indeed,  recognizable 
only  by  the  thermometer ;  the  whole  fever  is  more  like  a  continued 
fever.  Subsequently  to  the  nmth  day  usually  the  remissions  are  very 
marked,  the  difference  between  the  temperature  in  them  and  the  ex- 
acerbations being  three  degrees  or  more.  The  exacerbations  become 
less  and  less  high,  and  soon  cease,  the  temperature  falling  perhaps 
previously  to  below  the  norm.  In  cases  in  which  the  fever  remains 
for  a  long  time  continuous,  irregular  remissions  occur,  especially 
towards  the  end,  though  the  fever  may  preserve  its  continued  type 
until  it  gradually  ceases. 

Fig.  81. 


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Temperatuie  in  a  case  of  remittent  fever  of  moderate  severity,  ending  in  recovery  on  the  twelfth 
day.    The  chart  shows  also  the  pulse  and  the  respiration. 


The  average  duration  of  the  fever,  unless  protracted  by  complica- 
tions, is  from  nine  to  twelve  days.  Its  most  common  form  is  quotidian, 
or  rather,  perhaps,  double  tertian,  the  exacerbations  of  alternate  days 
corresponding  in  severity,  in  duration,  and  even  in  the  nature  of  the 
symptoms.  Sometimes  there  are  two  exacerbations  in  twenty-four 
hours, — a  duplicated  quotidian, — or  the  paroxysms  have  a  tertian 
form.  The  exacerbations  may  occur  any  time  in  the  twenty-four 
hours  ;  in  many  instances  morning  exacerbation  is  noticed,  and  I  have 


FEVERS.  843 

met  with  more  cases  in  which  the  paroxysm  comes  on  in  tlie  after- 
noon than  in  the  evening. 

The  urine  in  remittent  fever  presents  much  the  same  changes, 
though  in  a  different  degree,  as  those  occurring  in  intermittent  fever. 
During  the  active  stages  of  the  fever  there  is  an  increase  of  urea,  not 
simply  above  the  standard  of  health,  but  even  above  that  in  inter- 
mittent fever ;  and  this  increase  of  urea  is  attended  with  a  diminution 
of  uric  acid — unlike  what  happens  during  the  paroxysms  of  ague — 
and  of  the  coloring  and  extractive  matter ;  while,  as  convalescence 
sets  in,  the  urea  decreases  in  amount,  and  the  other  ingredients  men- 
tioned increase.^  A  copious  deposit  of  urates,  forming  with  the  phos- 
phates as  it  were  a  critical  discharge,  is  noticed  as  the  fever  subsides, 
and  is  analogous  to  what  takes  place  after  the  paroxysm  in  intermit- 
tent fever.  At  no  stage  does  the  urine  contain  albumin,  as  it  often 
does  in  typhus,  and  as  it  generally  does  in  yellow  fever ;  but,  as  in 
intermittent,  it  may  contain  sugar. 

Remittent  fever  is  readily  recognized :  the  rise  and  fall  of  its 
febrile  signs  are  too  striking  to  escape  observation.  Its  characteristic 
traits  are  closely  allied  to  those  of  intei-mittent  fever.  But  there  are 
these  points  of  contrast :  in  intermittent  fever  each  paroxysm  begins 
with  a  chill,  which  is  not  the  case  in  remittent  fever ;  for  after  the  first 
paroxysm  there  is  rarely  a  marked  chill,  and  even  the  chill  ushering 
in  the  disease  is  usually  not  violent.  After  each  febrile  exacerbation 
comes  an  abatement, — not  an  intermission,  for  the  thermometer  shows 
that  the  fever  does  not  leave ;  the  tongue  remains  coated,  and  the  gas- 
tric derangement  does  not  entirely  cease ;  the  patient  is  not  well. 
The  symptoms  rise  and  decline ;  they  do  not,  as  in  ague,  appear  and 
disappear.  In  both  affections  we  may  have  herpes  labialis  at  the 
decline,  but  it  is  more  common  in  remittent  than  in  intermittent. 

Owing  to  the  jaundice  in  many  cases  of  bilious  remittent  fever, 
the  disease  is  often  mistaken  for  acute  congestion  of  the  liver,  or  acute 
catarrhal  jaundice.  Here,  again,  the  exacerbations  and  remissions  in 
the  temperature  serve  as  distinguishing  marks  ;  and  so,  too,  in  sepa- 
rating the  gastric  complications  of  bilious  remittent  fever  from  acute 
gastric  inflammation.  The  severe  headache  is  also  a  distinctive  feature 
of  value ;  so  is  the  herpes  labialis.  But  of  greatest  importance  and 
conclusive  is  the  finding  of  the  malarial  parasites. 

Under  ordinary  circumstances  there  is  very  little  likelihood  of  con- 
founding with  each  other  typhoid  and  remittent  fevers.  The  lines 
between  the  two  diseases  are  too  strongly  drawn :  no  marked  perio- 

^  Joseph  Jones,  Observations  on  Malarial  Fever. 


844  MEDICAL  DIAGNOSIS. 

dicity  exists  in  typhoid  fever,  nor  are  vomiting  and  jaundice  often  seen  ; 
and,  on  the  other  hand,  we  find  no  diarrhoea,  no  eruption,  except  at 
times  herpes  and  urticaria,  no  thoracic  symptoms,  no  deafness,  and 
no  very  great  prostration  in  remittent  fever,  and  the  symptoms  are 
strikingly  influenced  by  quinine.  Very  decided  periodicity  may  be 
witnessed  in  typhoid  fever  as  it  is  approaching  a  favorable  termination; 
the  afternoon  or  evening  rise  of  temperature  is  most  marked,  the 
morning  remission  very  great.  Here  a  knowledge  of  the  previous 
history  of  the  case  and  the  Widal  test  guard  against  error.  We  shall 
presently  again  refer  to  the  symptoms  of  periodicity  in  examining  into 
typho-malarial  fever. 

Further,  not  infrequently,  after  an  attack  of  remittent  fever  has 
lasted  for  ten  or  twelve  days,  these  symptoms  are  noticed  :  great  mus- 
cular debility,  jerking  of  the  tendons,  picking  at  the  bedclothes,  dark, 
dry  tongue,  and  weak  pulse,  perhaps  diarrhoea.  The  fever  becomes 
of  a  continued  type.  It  is  these  cases  which  have  given  rise  to  the 
opinion  that  bilious  fever  often  changes  into  typhoid  fever.  But  in 
reality  it  is  not  the  specific  typhoid  fever,  with  its  enteric  lesions,  but 
a  typhoid  condition,  that  is  developed.  The  Widal  test  is  negative  ; 
malarial  organisms  are  found  in  the  blood. 

During  the  exacerbations  of  remittent  fever  the  cerebral  symp- 
toms are  sometimes  almost  identical  with  those  of  an  acute  brain- 
affection.  There  is  severe  headache,  with  violent  beating  of  the  arte- 
ries of  the  neck  and  face,  a  wild  eye,  intolerance  of  light,  and  even 
delirium.  Were  the  patient  now  seen  for  the  first  time,  he  would  be 
pronounced  to  be  laboring  under  acute  meningitis.  Suddenly  the  pulse 
loses  its  throbbing  character,  a  perspiration  covers  the  surface,  and, 
unexpectedly,  the  cerebral  disturbance  ceases  until  the  next  paroxysm 
redevelops  it.  Cases  of  this  kind  are  readily  enough  recognized,  if  we 
know  something  of  their  history.  If  we  are  not  familiar  with  it,  we 
have  to  await  the  remission  for  their  explanation  ;  and  after  the  sudden 
cessation  of  the  signs  of  disorder  of  the  brain  it  is  hardly  possible  to 
have  doubts  as  to  the  meaning  of  the  acute  nervous  symptoms,  should 
they  recur.  But  occasionally  these  show  themselves  under  circum- 
stances where  a  malarial  poison  is  not  suspected  to  be  at  work : 

A  young  gentleman  of  studious  habits,  while  diligently  preparing 
for  a  college  examination,  was  seized  with  violent  headache  and 
fever.  The  sense  of  fulness  in  the  head  was  unbearable,  the  fever 
was  high,  there  was  nausea  with  great  gastric  irritability.  These 
symptoms  lasted  for  nearly  twenty-four  hours,  and  then  subsided  in 
the  forenoon,  to  become  aggravated  in  the  evening.  Delirium  followed 
by  great  drowsiness  was  perceived  at  an  early  hour  of  the  third  day 


FEVERS.  845 

of  the  disease.  The  case  now  assumed  a  very  alarming  aspect.  Local 
bloodletting  was  resorted  to  with  some  relief,  .and  in  a  few  hours  the 
symptoms  were,  fortunately,  favorably  modified :  the  headache  was 
much  less,  the  mind  was  again  quite  clear.  Although  the  patient  had 
never  suffered  from  a  malarial  fever,  he  had  spent  part  of  his  summer 
vacation  in  the  marshy  neighborhood  of  Washington  ;  but  several 
months  had  elapsed,  and  winter  was  setting  in.  The  time  of  the  year 
was  not  in  favor  of  malaria.  But  the  evident  remission  in  the  cerebral 
symptoms,  the  coated  state  of  the  tongue,  and  the  malarial  look  of 
the  countenance,  that  became  daily  more  apparent,  decided  me  upon 
administering  quinine.  The  evening  exacerbation  came,  but  was  far 
less  severe.  The  nature  of  the  case  was  now  evident :  the  quinine 
treatment  was  vigorously  pursued,  and  the  patient  soon  recovered. 

The  violent  headache  and  delirium  were  in  this  case  observed  to 
be  in  connection  Avith  well-defmed  febrile  signs.  Occasionally  one  or 
both  of  the  symptoms  mentioned  last  during  remission,  while  the 
fever  abates.  I  have  even  met  with  them  occurring  in  paroxysms 
without  fever  being  present,  as  in  the  following  case  seen  a  number  of 
years  ago : 

A  young  lady  of  delicate  constitution  was  attacked,  in  September, 
with  remittent  fever.  The  disease  ran  its  course  without  any  unusual 
symptoms  ;  a  violent  headache,  but  little,  if  any,  wandering  of  the  mind 
being  observed  during  the  daily  exacerbations.  After  the  tenth  day 
the  fever  lessened,  and  the  disease  assumed  a  continued  type  ;  yet 
soon  afterwards,  as  convalescence  seemed  to  be  established,  every 
evening  for  three  days,  between  five  and  six  o'clock,  a  boisterous 
delirium  set  in,  lasting  for  three  or  four  hours,  and  once  nearly  all 
night.  It  was  followed  by  a  profound  sleep,  from  which  she  woke  up 
with  a  clear  mind.  During  these  fits  the  pulse  was  not  accelerated, 
and  there  was  no  fever.  The  third  attack  was  not  so  very  severe,  as 
the  patient  was  already  in  part  under  the  influence  of  decided  doses 
of  quinine  ;  another  was  prevented  by  this  drug. 

Both  these  cases  were  seen  before  the  discovery  of  the  malarial 
parasite ;  the  presence  of  this  would  have  at  once  determined  their 
true  nature.  In  both  the  symptoms  approached  those  of  the  con- 
gestive type  of  the  disease,  and  the  issue  appeared  at  one  time  doubt- 
ful. Generally  speaking,  remittent  fever,  unless  it  be  of  the  con- 
gestive variety,  has  a  favorable  prognosis.  It  is  difficult  for  us,  living 
in  a  century  in  which  the  remarkable  effects  of  quinine  are  so  well 
understood,  to  believe  tliat  the  complaint  was  once  so  fatal,  and  that 
so  many  deaths  should  have  taken  place  from  a  disorder  over  which 
we  now  exercise  so  undoubted  a  control.     But  the  long  list  of  dis- 


846  MEDICAL  DIAGNOSIS. 

tinguished  names  that  have  faUen  victims  to  it,  among  them  Crom- 
weh,  James  I.,  and  the  Emperor  Charles  V./  proves  the  medical  skill 
of  former  times  to  have  been  insufficient  for  its  cure.  In  our  day,  the 
consequences  of  remittent  fever  are  more  to  be  dreaded  than  the  dis- 
ease itself.  We  often  fmd,  as  its  sequelae,  obstinate  intermittents, 
enlargement  of  the  liver  and  spleen,  dropsy,  protracted  anaemia,  head- 
ache, and  impaired  activity  of  mind. 

In  children,  a  fever  of  remittent  type  is  observed,  called  infantile 
remittent,  which  is  rarely  a  miasmatic  disorder.  It  is  often  a  gastro- 
enteritis connected  with  verminous  irritation  or  produced  by  errors  in 
diet ;  or  a  typhoid  fever, — an  affection  which  now  and  then  occurs  even 
in  very  young  children.  What  has  given  rise  to  this  confusion  is,  that 
all  febrile  diseases  in  children  exhibit  a  much  greater  periodicity  than 
in  adults,  and  in  aU  some  cerebral  symptoms  are  apt  to  be  present. 
To  distinguish  the  two  maladies  mentioned  from  true  remittent  fever, 
we  must  study  particularly  their  manner  of  beginning  and  their 
probable  origin,  and  note  the  peculiarities  of  the  abdominal  symptoms. 
Then  we  may  lay  stress  on  the  irregular  mode  and  the  unequal  dura- 
tion of  the  febrile  exacerbations.  Sometimes,  also,  by  close  scrutiny, 
the  characteristic  eruption  of  a  low  continued  fever  may  be  found  in 
an  apparent  remittent. 

But  some  of  these  cases  of  infantile  remittent  fever  are  really 
of  malarial  origin ;  even  in  young  children  this  may  be  their  source. 
I  saw,  for  instance,  some  years  ago,  a  little  girl,  three  years  of  age, 
who  had  a  distinctly  malarial  remittent  fever,  which  was  checked  by 
antiperiodics.  During  the  violent  exacerbations  she  was  very  deliri- 
ous ;  her  face  had  a  most  anxious,  frightened  look  ;  her  screams  could 
be  heard  ah  over  the  house.  In  the  remissions  she  was  perfectly 
sensible,  but  there  was  gastric  irritability,  and  the  bowels  were  very 
constipated.  I  have  met  with  a  similar  case  in  an  infant  of  eighteen 
months. 

Pernicious  or  Congestive  Fever. — This  is  a  malignant,  malarial 
fever,  which  may  be  either  of  the  intermittent  or  of  the  remittent 
form,  and  with  rare  exceptions  depends  upon  infection  with  the  aestivo- 
autumnal  parasite  which  is  present  in  large  numbers.  A  special  form 
of  the  eestivo-autumnal  parasite,  the  malignant  tertian  parasite,  is  held 
to  be  the  cause  of  the  malignancy.  But  this  is  not  certain.  Manna- 
berg  lays  stress  on  individual  predisposition  and  on  the  anatomical 

1  From  the  record  of  the  Emperor's  illness,  as  given  by  the  historian  Mignet 
(Charles  V  au  Monastere  de  Yuste),  we  may  learn,  what  fortunately  now  we  hardly 
have  an  opportunity  of  observing,  the  features  of  remittent  fever  when  left  to 
itself. 


FEVERS.  847 

lesions  produced,  such  as  occlusion  of  the  finer  blood-vessels  with  the 
infected  blood-corpuscles.  If  ordinary  ^stivo-autumnal  fever  be  not 
treated,  it  tends  to  become  pernicious.  The  pernicious  attacks  are  of 
the  tertian  or  the  cjuotidian  type.  While  they  are  at  their  height, 
there  is  intense  congestion  of  one  or  several  internal  organs,  with  a 
dangerous  perversion  of  the  function  of  innervation.  From  this  state 
the  patient  may  rally,  but  only  to  fall  a  victim  to  another  paroxysm, 
unless  art  intervene.  The  temperature  during  the  chill  and  subse- 
quent fever  ranges  from  104°  to  108°.  Sugar  is  found  in  the  urine 
much  more  commonly  than  in  ordinary  intermittent  fever. 

The  symptoms  of  this  violent  malady  vary  according  to  the  organ 
more  specially  disturbed,  and  to  the  extent  of  the  derangement  of  the 
nervous  system.  We  have,  thus,  several  distinct  varieties,  of  which  I 
shall  describe  the  prominent. 

The  gastro-enteric  form  is  common  in  our  Southwestern  States. 
Its  distinctive  features  are  nausea  and  vomiting,  purging  of  thin  dis- 
charges mixed  with  blood,  intense  thirst,  and  an  equally  intense  desire 
for  air.  There  is  little  abdominal  pain  or  tenderness,  but  a  weak,  fre- 
quent pulse,  and  very  great  restlessness.  The  patient  complains  of  a 
sense  of  sinking  and  of  weight,  and  of  burning  heat  in  the  stomach. 
His  breathing  is  deep-drawn ;  to  each  expiration  succeed  two  short 
inspirations.  The  face,  hands,  and  feet  are  pale  and  cold  ;  the  features 
shrunken.  Sometimes  these  symptoms  continue  for  several  days,  and 
gradually  increase  in  intensity,  in  spite  of  nature  making  efforts  at  re- 
action. More  frequently  reaction  does  take  place ;  the  temperature 
is  very  high,  the  pulse  feeble,  and  the  stormy  symptoms  subside  or 
wholly  yield,  until  another  outbreak,  which  is  very  apt  to  be  deadly, 
occurs.  The  usual  length  of  the  fatal  paroxysm  is  stated  by  Parry ,^ 
to  be  from  three  to  six  hours. 

The  thoracic  variety  of  the  malady  is  often  combined  with  the  one 
just  described.  Its  most  characteristic  trait  is  violent  dyspnoea,  caused 
by  overwhelming  congestion  of  the  lungs.  It  is  perhaps  the  most 
rapidly  destructive  of  all  the  forms  of  the  disastrous  affection. 

In  the  cerebral  variety  the  temperature-curve  is  not  that  of  any 
special  type  of  malarial  fever.  The  abnormal  state  of  the  brain  mani- 
fests itself  either  by  coma  or  by  delirium.  In  the  former  case  there  is 
usually  preceding  stupor  with  occasional  delirium ;  the  pulse  is  slow 
and  full ;  the  face  is  dull,  and  either  flushed  or  livid ;  indeed,  some  of 
the  symptoms  which  are  observed  in  apoplexy  show  themselves. 
When,  on  the  other  hand,  delirium  is  marked,  we  have  much  the 

'  Amer.  Journ.  Med.  Sci.,  July,  1843. 


848  MEDICAL  DIAGNOSIS. 

same  morbid  phenomena  as  in  acute  meningitis  ;  the  patient  is  wild ; 
he  sings,  he  cries.  He  may  die  in  this  state  without  coma  super- 
vening ;  but  a  comatose  condition  generally  succeeds  rapidly  to  the 
fierce  excitement.  Should  recovery  take  place,  the  delirium  gradually 
ceases. 

Another  variety  much  dwelt  upon  is  the  so-called  algid  form. 
This  is  not  often  seen  in  this  country ;  but  is  not  uncommon  in  Cor- 
sica and  Algeria.  The  disease  is  more  than  a  mere  continuation  of 
the  cold  stage  of  a  paroxysm :  usually  the  characteristic  symptoms 
manifest  themselves  during  the  period  of  reaction.  The  pulse  slackens, 
and  finally  ceases ;  the  extremities,  face,  and  trunk  become  in  suc- 
cession rapidly  cold.  There  is  no  thirst ;  the  skin  feels  like  marble  ; 
the  breath  is  cold  ;  the  voice  broken.  The  mind  is  clear  ;  the  expres- 
sion of  the  countenance  impassive  and  like  that  of  a  dead  man. 
There  may  be  frequent  attacks  of  syncope  ;  or  excessive  sweating ;  or 
vomiting  and  choleraic  discharges  occur.  These  symptoms  go  on 
steadily  towards  death,  unless  decided  reaction  be  brought  about. 

In  none  of  these  forms  of  congestive  fever  is  the  first  paroxysm 
apt  to  be  of  a  pernicious  character.  In  the  majority  of  instances  the 
disease  begins  as  ordinary  periodic  fever,  and  it  is  only  in  the  second 
or  third  paroxysm  that  the  alarming  symptoms  appear.  Nor  is  the 
first  pernicious  paroxysm  likely  to  prove  mortal ;  generahy  it  is  not 
until  the  second  or  third  that  a  fatal  issue  is  to  be  apprehended. 
Proper  watchfulness  will  sometimes  detect,  even  at  the  onset  of  the 
attack, — by  the  unusual  prolongation  of  the  cold  stage,  or  by  the  irregu- 
larity of  the  pulse,  or  by  the  great  sensitiveness  in  the  splenic  region 
and  by  the  pain  which  pressure  there  may  occasion  all  over  the  body, 
or  by  an  imperfect  hot  stage,  or  by  the  feeling  of  internal  heat  while 
the  surface  is  reahy  cold, — the  danger  that  is  approaching,  and  arrest 
its  further  steps  by  the  bold  use  of  antiperiodics. 

The  cause  of  this  desperate  disease  is  a  highly  active  malarial 
poison,  and  very  likely  some  peculiarities  of  the  malarial  parasites. 
Should  the  patient  even  weather  the  first  attack  completely,  he  is  not 
wholly  out  of  danger ;  he  may  have  a  second  seizure  quite  as  perilous 
within  the  same  season.  Dock  ^  has  recorded  in  detail  the  study  of  a 
case  of  pernicious  malarial  fever  characterized  by  an  enormous  de- 
velopment of  Plasmodia  in  the  blood,  with  consequent  anaemia  and 
melan^emia  ;  parenchymatous  degeneration  and  inflammation  in  liver, 
kidneys,  and  stomach ;  thrombosis  in  various  organs ;  hyperplasia  of 
the  spleen  and  lymphatic  glands.     On  micro-chemical  examination  the 


1  Amer.  Journ.  Med.  Sci.,  April,  1894,  p.  379. 


FEVERS.  849 

pigment  in  the  malarial  parasites  failed  to  respond  to  tests  for  iron, 
while  deposits  in  the  tissues  themselves  yielded  such  reaction. 

Hemorrhagic  Malarial  Fever. — Closely  connected  with  congestive 
fever,  indeed  a  form  of  it  is  that  pernicious  malady  which  is  known 
as  the  yellow  disease,  icterode  pernicious  fever,  malarial  haematuria, 
hemorrhagic  malarial  fever,  or  black-water  fever.  It  is  the  same  dis- 
ease as  that  which  some  of  the  French  writers  have  long  described  as 
hgematuric  bilious  fever,  and  is  found  in  intensely  malarial  places, 
sometimes  in  epidemics.  It  usually  occurs  in  those  who  have  already 
suffered  much  from  malarial  fever,  and  is  almost  always  ushered  in 
by  a  marked  chill,  longer  usually  and  more  intense  than  the  patient 
has  had  in  the  preceding  seizure  of  intermittent, — for  often  the  dan- 
gerous paroxysm  is  preceded  by  one  of  ordinary  kind.  Soon  after 
the  protracted  chill,  distressing  nausea  and  vomiting  are  noticed,  as 
well  as  headache,  great  restlessness,  and  quickly  developed,  deep  jaun- 
dice. The  fever  which  follows  the  chill  is  not  high,  the  pulse  is  rarely 
extremely  rapid,  the  patient  is  very  thirsty.  In  a  few  hours  after  the 
chill,  pain  in  the  right  hypochondrium,  in  the  epigastrium,  and  over 
the  kidneys  is  encountered,  and  a  dark-colored,  bloody  urine  is  voided. 
Sometimes  hemorrhages  occur  also  from  the  nose  and  bowels.  The 
type  of  the  fever  is  either  intermittent  or  remittent,  occasionally  it  is 
continuous.  The  bloody  urine — for  I  know  the  dark-colored  urine, 
from  the  specimens  I  have  examined,  to  be  bloody  or  to  contain  large 
quantities  of  dissolved  haemoglobin — is  at  times  associated  with  con- 
siderable albumin  and  with  tube-casts.  The  parasite  is  of  the  aestivo- 
autumnal  form.  Baccelli '  attributes  the  haemoglobinuria  not  to  the 
malarial  parasite,  but  to  its  toxines. 

If  the  case  progress  unfavorably,  the  pulse  rises,  cold  sweats  occur, 
purpuric  spots  appear  on  the  skin,  and  the  signs  of  uraemic  poisoning 
are  not  unusual.  In  the  intermission  or  remission  the  symptoms  abate 
considerably,  jaundice  and  bloody  urine  cease  to  a  great  extent,  per- 
haps almost  entirely, — at  least  this  is  true  of  the  latter  symptom, — 
but  they  recur  in  the  paroxysms,  which  may  happen  every  day  or 
every  ten  or  twelve  hours. 

The  disease  may  prove  fatal  In  three  days  ;  but  generally  it  lasts 
longer.  Convalescence  sets  in  slo\yly,  and  not  until  the  urine  has  en- 
tirely and  permanently  cleared.  It  is  thought  by  several  observers, 
especially  by  Tomaselli,  Ughetti,  and  other  Italians,  that  the  disease 
is  not  due  to  the  malarial  infection,  but  to  the  toxic  influence  of 
quinine.     But  this  view  is  not  adopted  in  this  country. 

'  Policlin.,  Jan.  1897. 


850  MEDICAL   DIAGXOSIS. 

As  regards  the  diagnosis  of  the  disease,  there  are  but  two  diseases 
that  closely  resemble  it.  One  is  intermittent  hcemoglohinuria.  Now. 
undoubtedly  some  of  the  recorded  cases  of  this  are  cases  of  the 
malady  under  discussion  :  but  in  those  to  wliich  the  name  can  be 
fairly  given  the  absence  of  malarial  elements  in  the  blood,  of  jaundice. 
of  red  blood-disks  in  the  urine,  and  the  want  generally  of  fever,  supply 
the  distmguishing  traits.  From  yelloic  fever,  for  wMch  hemorrhagic 
malarial  fever  may  be  mistaken,  it  differs  in  the  speedy  occurrence  of 
marked  jaundice,  in  the  bloody  urme.  in  the  extreme  rarity  of  black 
vomit,  m  the  course  of  the  fever  with  its  returrmg  paroxysms,  and  in 
the  high  degree  of  malarial  poisonmg  which  the  history  of  the  case 
and  the  examination  of  the  blood  proves. 

Then,  again,  the  malarial  poison  may  affect  the  kidneys,  producing 
altered  secretion,  transitory  albuminuria,  or  even  nephritis.  Albumi- 
nuria was  found  by  Thayer  ^  ui  nearly  half  the  cases  of  the  malarial 
fevers  of  Baltimore,  and  much  more  frequently  in  the  aestivo-autumnal 
infections  than  in  the  other  forms.  In  this  form,  too,  acute  nephritis  is 
more  common  than  in  the  other  varieties.  The  malarial  infection  may 
lead  to  chronic  renal  disease.  In  all  these  kidney  complications  the 
history  of  the  case  and  the  examination  of  the  blood  for  the  malarial 
parasites  are  of  the  greatest  importance.  The  cases  of  nephritis  fol- 
lowing ha?mogiobinuria  are  always  grave. 

Before  proceedmg  to  the  discussion  of  another  subject.  I  shall 
here  devote  a  few  pages  to  the  consideration  of  some  of  the  irregular 
forms  and  modifications  of  malarial  poisoning,  and  to  its  share  in 
producing  febrile  disorders  of  blurred  and  uncertain  type.  Practi- 
cally, this  is  of  great  importance,  and  specially  of  importance  to 
American  physicians. 

In  the  first  place.  I  shall  speak  of  the  chronic  malarial  poisoning. 
or  nwlarial  cachexia,  so  often  seen  among  inhabitants  of  malarial  dis- 
tricts. It  manifests  itself  by  lassitude,  debility,  torpor  of  the  liver, 
and  enlargement  of  the  spleen.  The  stools  are  often  black,  the  diges- 
tion is  impaired,  the  complexion  sallow.  Occasionally  attacks  of 
jaundice  occur,  which  rather  relieve  than  aggravate  the  unhealthy 
state  of  the  system.  Sometimes  the  noxious  influence  shows  itself  in 
another  way  :  the  patient  is  seized  with  nausea,  and  with  gastric  irri- 
tability so  great  that  almost  everything  he  takes  is  instantly  rejected. 
The  tongue  is  coated,  the  skin  dryish  ;  but  he  has  little  if  any  fever. 
The  bowels  are  confined,  the  urine  is  turbid.  He  is  restless,  and  as 
weak  as  if  he  had  typhoid  fever :  but  he  has  neither  an  eruption  nor 


1  Amer.  Journ.  Med.  Sci.,  Dec.  1898. 


FEVERS.  851 

diarrhoea.  His  sleep  is  disturbed,  and  he  often  suffers  with  hyperses- 
thesia  of  the  scalp,  and  neuralgic  pain  shooting  over  the  forehead  and 
causing  twitching  of  the  eyelids.  After  remaining  from  six  to  seven 
days  in  this  condition,  his  nails,  perhaps  at  a  certain  hour  every  day, 
are  noticed  to  become  bluish  ;  or  he  feels  chilly,  and  a  slight  fever  im- 
mediately afterwards  sets  in.  The  return  of  these  febrile  symptoms 
is  checked  by  quinine,  and  the  patient  enters  upon  a  slow  convales- 
cence, remaining  for  a  long  time  enfeebled.  Again,  there  may  be 
headache,,  coming  on  at  a  certain  hour,  associated  with  rise  of  temper- 
ature ;  or  attacks  of  diarrhoea  or  of  vomiting ;  or  a  persistent  slight 
febrile  state  with  the  temperature  from  99°  to  100°,  with  occasional 
rises.  We  also  encounter  malarial  diseases  of  the  eye,  pulmonary 
congestion  of  malarial  origin  with  the  parasites  in  the  sputum, 
malarial  aphasias,^  malarial  atony  of  the  bladder,"  neuralgias,  espe- 
cially of  the  supraorbital  and  intercostal  nerves,  and  malarial  palsies. 

Fig.  82. 


A  drop  of  blood  taken  from  the  finger  of  a  man  the  subject  of  malarial  cachexia.  The  granules 
of  pigment,  as  well  as  the  larger  fragments  of  irregular  form,  are  seen  among  the  blood-globules. 
The  pigment  was  for  the  most  part  black ;  some  of  the  particles  were  reddish  brown. 

In  these,  as  m  a  case  under  my  care  at  the  Pennsylvania  Hospital  in 
1889,  the  detection  of  the  malarial  corpuscles  in  the  blood  led  to  the 
diagnosis  of  the  affection.  Indeed,  in  any  of  these  doubtful  and  sus- 
pected cases,  in  which,  too,  the  periodicity  may  ultimately  be  lost, 
careful  and  repeated  blood  examination  is  essential.  The  usual  form 
of  parasite  found  is  the  ivstivo-autumnal ;  pigmented  leucocytes  are 
also  not  uncommon.     But  as  regards  the  parasites  in  all  these  in- 

'  Longaycf,  Indian  Lancet,  Jan.  1897. 
■^  Marion,  Now  York  Med.  Jouin.,  18i>7. 


852  MEDICAL  DIAGNOSIS. 

stances  of  chronic  malaria]  infection,  they  may  not  be  detected  except 
after  several  examinations. 

In  the  malarial  cachexia  we  have  not  only  the  ordinary  signs  of 
anaemic  blood,  and  with  these  frequently  enlargement  of  the  spleen, 
dropsy,  and  hemorrhagic  tendencies,  but  the  blood  itself  exhibits  pecu- 
liar signs.  It  will  show  not  only  the  malarial  parasites,  but  consider- 
able pigment,  the  result  of  the  destructive  changes  in  the  haemoglobin 
of  the  red  corpuscles.  Besides  the  black  pigment  there  is  also  a  yel- 
lowish or  rusty-colored  pigment,  the  seat  of  which,  however,  is  more 
especially  the  spleen,  liver,  and  bone-marrow.  The  pigment  granules 
are  found  not  only  within  the  malarial  parasite,  but  also  exist  free, 
and,  accumulating  in  the  capillaries,  produce  clogging,  with  secondary 
results  of  disturbed  circulation,  and  altered  nutrition  in  the  brain, 
liver,  kidney,  or  of  whatever  part  the  vessels  should  supply.  For 
the  pigment  to  be  of  diagnostic  value,  it  must  be  present  in  decided 
amounts ;  for  J.  F.  Meigs '  found  pigment  in  the  blood  of  those  who 
had  never  had  malarial  fever  or  had  never  presented  any  signs  of 
malarial  poisoning.  In  the  malarial  blood  the  number  of  leucocytes 
is  diminished,  with,  as  Thayer  states,  a  relative  increase  in  the  large 
mononuclear  forms. 

Typho-Malarial  Fever. — Following  the  observations  of  Wood- 
ward during  our  civil  war,  the  thought  obtained  wide  currency  that 
there  existed  a  special  form  of  fever,  typho-malarial,  running  a  defi- 
nite course  and  with  characteristic  lesions.  It  was  supposed  to  be  a 
hybrid,  generated  by  the  malarial  and  typhoid  poisons,  with,  in  the 
case  of  the  camp  fevers,  an  admixture  of  scurvy ;  and  the  so-called 
"  Chickahominy  fever,"  seen  among  soldiers  who  contracted  it  in  the 
swamps  of  the  Chickahominy,  was  its  most  striking  illustration.  But 
the  verdict  of  the  profession  now  is,  that  there  is  no  such  fever  as  a 
distinct  disease.  Yet  with  our  present  means  of  research  it  can  be 
proved  that  there  is  undoubted  coexistence  of  the  malarial  and 
typhoid  infections.  There  are  malarial  cases  in  which  true  enteric 
fever  happens,  or  typhoid-fever  cases  in  which  the  malarial  poison 
has  been  held  in  check  by  the  typhoid  infection,  and  does  not  show 
itself  until  late  in  the  disease  ;  cases  beyond  doubt  clinically,  in  which 
the  Widal  reaction  is  positive,  and  malarial  organisms  are  found  in 
the  blood.  Thompson  ^  has  reported  several  such  instances  of  con- 
current disease;   Lyon^   has   brought   together  others;   and   I   have 


'  Pennsylvania  Hospital  Reports,  vol.  i. 
-  Amei'.  Journ.  Med.  Sci.,  Aug.  1894. 
Mbid.,  Jan.  1899. 


FEVERS.  853 

records  of  twelve,  one  of  which  was  separately  published  ^  in  a  clinical 
lecture,  and  ten  of  which  were  subsequently  analyzed.  Pathologi- 
cally, also,  a  number  have  been  studied  in  an  interesting  communi- 
cation by  Muehleck.^ 

Now,  it  is  a  question  whether,  irrespective  of  the  Widal  test  and 
the  microscopic  examination  of  the  blood  for  malarial  elements,  such 
cases  can  be  recognized  clinically.  Not  with  certainty.  Yet  they 
may  be  suspected  from  chills  occurring  late  in  the  disease,  and  de- 
cided sweating  following ;  from  obvious  and  apparently  causeless 
temperature-rises,  and  marked  irregularity  of  temperature  without 
such  rises ;  and  from  long  duration  of  the  fever.  In  all  such  cases 
repeated  examination  of  the  blood  for  malarial  organisms  should  be 
made.  The  parasites  I  found  were  tertian  or  sestivo-autumnal,  and 
frequently  decidedly  pigmented ;  an  instance  of  the  quartan  type  in 
one  of  these  combined  typhoid  and  malarial  fevers  has  been  published 
by  Craig.^ 

There  is,  then,  such  a  morbid  condition  as  a  typho-malarial  fever, 
but  not  as  a  separate  disease,  and  not  in  the  sense  in  which  it  has 
been  understood.  It  is  a  concurrence  rather  than  a  blending, — a 
typhoid  fever,  after  all ;  and,  if  we  are  to  give  it  a  name,  malario- 
typhoid  would  be  appropriate. 

Eruptive  Fevers. 

The  eruptive  or  exanthematous  fevers  form  a  group  having  numer- 
ous features  in  common.  They  are  characterized  by  a  period  of  incu- 
bation, during  which  the  poison  lies  dormant ;  by  a  fever  preceding 
the  eruption ;  by  an  eruption  which  presents  a  distinct  aspect  in  each 
disease,  and  which  pursues  a  deflnite,  clearly  defined  course  until' it, 
and,  with  it,  the  febrile  malady,  disappears.  Moreover,  they  are  all 
very  prone  to  occasion  serious  sequelae  ;  are  all,  in  the  main,  disorders 
of  childhood ;  rarely  attack  the  same  person  twice ;  and  are  conta- 
gious. These  remarks  apply  particularly  to  the  three  chief  exanthem- 
atous fevers :  scarlet  fever,  measles,  and  smallpox.  In  great  part, 
too,  they  hold  good  in  regard  to  erysipelas,  described  here  in  connec- 
tion with  the  eruptive  fevers. 

Scarlet  Fever. — Scarlatina  affects  both  children  and  adults,  and 
is  marked  by  great  heat  of  skin,  frequent  pulse,  sore  throat,  and  an 
early  scarlet  eruption.  These  symptoms  are  preceded  by  an  uncer- 
tain, generally  a  short,  period  of  incubation,  but  soon  exhibit  their 

'  Philadelphia  Med.  Journal,  May  6,  1899. 

■'  Il.id.,  May  20,  1899. 
•'  Iliid..  June  17.  189i). 


854  '     MEDICAL   DIAGNOSIS. 

striking  features.  The  febrile  excitement  is  characteristic ;  the  skin  is 
very  hot  and  generally  dry,  and  the  rapidity  of  the  pulse  so  great  that 
often  by  this  sign  alone  we  may,  especially  in  the  midst  of  an  epidemic, 
prechct  the  coming  eruption.  Vomiting,  too,  is  a  frequent  symptom 
at  the  beginning  of  the  illness.  The  temperature,  which  may  reach 
between  105°  and  106°,  does  not  fall  with  the  appearance  of  the 
eruption.  The  highest  temperature  occurs  on  the  second  or  the  third 
day.-^  The  temperature  continues  high  until  the  eruption  is  completed 
and  at  its  height.  It  slowly  declines  as  this  fades,  and  with  the  occur- 
rence of  desquamation  attains  the  norm  ;  but  it  may  persist,  mth 
marked  morning  remissions  and  evening  exacerbations,  when  the 
eruption  has  gone  and  dming  the  first  week  of  desquamation. 

The  rash  appears  on  the  second  day  of  the  disease.  It  comes  out 
almost  simultaneously  all  over  the  body,  although,  on  close  scrutiny, 
it  may  be  soonest  perceived  on  the  neck  and  the  breast.  At  first  the 
surface  exhibits  an  almost  uniform  red  blush,  which  disappears 
momentarily  on  pressure,  or  rather  pressure  leaves  a  wliite  stain  on 
the  skin,  which  quickly  again  reddens  from  the  periphery  to  the 
centre.  Soon,  however,  the  eruption  presents  an  unequal  aspect ;  it 
is  of  more  vivid  scarlet  hue  in  some  parts  of  the  body,  as  in  and 
around  the  flexures  of  the  joints,  and  is  not  everywhere  smooth. 
Here  and  there  are  seen  elevated  rough  points  of  darker  tint,  edged 
by  the  red  integument,  and  not  infrequently  vesicles  containing  a  tliin 
fluid.  The  skin  is  very  hot  and  itchy,  and  tumefied,  especially  on  the 
hands  and  feet.  The  eruption  declines  on  the  fourth  or  the  fifth  day  ; 
by  the  seventh  or  eighth,  the  cuticle  begins  to  come  away  in  large 
flakes.  Sometimes  the  rash,  when  at  its  height,  recedes  and  then 
appears  again.  In  malignant  cases  it  comes  out  late,  and  is  either 
pale  and  indistinct,  or  dark  and  li-^id.  In  some  instances  it  is  wantmg. 
Some  years  ago,  I  saw  tliis  "  scarlatma  sine  exanthemate"  in  a  lady, 
who,  watching  over  the  sick-bed  of  her  daughter,  contracted  the  dis- 
ease and  went  regularly  through  it,-  even  to  its  sequelse  of  disorder  of 
the  kidneys  and  swelling  of  the  salivary  glands,  but  in  whom  not  a 
trace  of  an  eruption  could  be  detected. 

The  sore  throat  of  scarlatina  is  almost  as  constant  and  as  charac- 
teristic as  the  scarlet  rash.  It  shows  early,  sometimes  before  the 
eruption,  and  rarely  waits  until  the  third  day  of  the  complaint.  At 
first  the  throat-affection  cdnsists  in  a  diffused  redness  extending  over 
the  tonsils,  palate,  and  half-arches,  and  in  a  swelling  of  the  tonsils : 

^Hatfield,  article  "Scarlet  Fever,'"  in  American  Text-Book  of  Disease?  of 
Children,  1894. 


FEVERS.  855 

the  patient  complains  of  pain  in  his  throat,  augmented  by  pressure 
and  by  swallowing,  and  of  stiffness  of  the  muscles  of  the  neck.  After 
a  few  days,  if  the  disorder  be  severe,  irritating  discharges  occur  from 
the  inflamed  surfaces,  and  patches  of  false  membrane  and  superficial 
ulcerations  are  seen  in  the  fauces.  The  glands  at  the  angle  of  the 
jaw  become  much  tumefied,  and,  by  pressing  on  the  cervical  vessels, 
produce  a  tendency  to  drowsiness  and  stupor.  These  are  grave  symp- 
toms ;  their  occurrence,  indeed,  is  indicative  of  one  of  the  main 
dangers  in  these  "  anginose"  cases  of  the  disease. 

The  false  membranes  which  are  developed  last  about  five  or  six 
days ;  they  form  as  well  as  reform  in  patches,  and  are  very  easily  re- 
moved. Sometimes  they  extend  to  the  larynx ;  but  this  does  not 
often  happen.  They  contain  masses  of  streptococci,  but  no  diphtheria 
bacilli,  unless  there  be  a  true  diphtheritic  complication.  Yet  this  is  a 
point  that  is  not  accepted  by  all  clinicians.  The  mortality  in  these 
mixed  cases  is  much  greater.^  The  acid  discharges  and  the  decom- 
posing membranes  often  occasion  a  most  fetid  breath. 

The  tongue  has  a  peculiar  look.  At  first  it  is  thickly  coated,  and  its 
borders  only  are  red ;  but  soon  the  fur  is  cast  off,  and  the  whole  organ 
becomes  very  red  and  its  papillae  prominent.  After  it  has  presented 
this  appearance  for  six  or  eight  days,  it  returns  to  its  normal  condition. 
In  bad  cases  it  is  extremely  dry  and  of  a  brownish  hue. 

There  is  always  marked  leucocytosis  in  scarlet  fever,  and  it  reaches 
its  maximum  in  the  first  few  days  of  the  disease ;  a  close  relationship 
exists  between  the  severity  of  the  rash  and  the  number  of  leuco- 
cytes ;  ^  and  the  return  to  normal  is  always  gradual. 

In  children  the  disease  frequently  sets  in  with  convulsions.  In 
truth,  cerebral  symptoms  of  one  kind  or  another  are  not  uncommon 
at  all  stages  of  the  malady.  In  some  cases  of  malignant  character, 
the  vomiting,  the  screams,  the  grinding  of  the  teeth,  the  occurrence  of 
delirium  and  insomnia,  make  the  attack  look,  at  the  onset,  like  one  of 
acute  meningitis ;  but  the  eruption  soon  sets  all  doubt  at  rest,  and, 
even  before  it  is  noticed,  the  great  heat  of  the  skin  and  the  extreme 
rapidity  of  the  pulse  point  to  the  source  of  the  mischief.  The  nervous 
symptoms  in  these  dangerous  instances  of  the  affection  do  not.  how- 
ever, cease  with  the  t-ruption  ;  they  may  last  to  the  end  of  the  malady. 
Sometimes  they  are  not  noticed  niilil  late  in  llie  disorder,  and  after 
the  period  of  desquamation  has  fully  begun ;  but  the  convulsions  and 


^  Chabade-Roussk.  ark.  patol.  kliii.  iihmI.  ilmkl,  Vvh.  1899,  (luoird   in  Medical. 
Mart,  July,  1899. 

^  Sevestre,  St.  Barthiiloiiicw's  Hos|).  Kcp.,  1897. 


856  MEDICAL   DIAGNOSIS. 

stupor — for  these  are  the  morbid  manifestations  then  more  specially 
encountered — are  owing  rather  to  a  diseased  state  of  the  kidneys  that 
has  been  induced,  than  to  the  immediate  effect  of  the  fever  poison. 

Occasional!}^  some  of  the  larger  joints  swell  up,  and  present  the  ap- 
pearance of  subacute  rheumatism.  The  joints  are  not,  however,  very 
painful  on  pressure,  and  generally  only  two  or  three  are  enlarged. 
Endocarditis  and  pericarditis  may  be  present  as  complications,  but 
occur  also  irrespective  of  articular  involvement,  as  does  chorea. 

Further  complications  of  the  disease  are  dropsies,  renal  heematu- 
ria,  pleurisy,  local  gangrene,  oedema  of  the  glottis,  neuritis,  diph- 
theria, and  profound  anaemia.  These  complications  do  not  usually 
arise  until  at  or  soon  after  the  period  of  desquamation  ;  sometimes 
they  lead  to  long-continued  disorder,  and  become  thus  the  most 
hazardous  of  the  sequelae.  Other  consequences  of  the  affection, 
lasting,  it  may  be,  for  years  after  the  febrile  attack,  are  a  tendency  to 
boils,  swelling  of  the  parotid  and  of  the  lymphatic  glands  of  the  neck, 
nasal  catarrh,  diarrhoea,  chronic  inflammation  of  the  eyelids,  and 
deafness  from  inflammation  extending  up  the  Eustachian  tube  to  the 
membrane  of  the  tympanum,  or  from  suppurative  destruction  in  the 
middle  ear.  Epilepsy  is  also  a  sequel  of  scarlet  fever,  more  cases 
being  consecutive  to  it  than  to  all  other  acute  diseases  combined.^ 
Optic  neuritis  may  follow  scarlet  fever,  without  organic  change  in  the 
brain. 

Of  all  these  morbid  states,  dro])sy  is  the  most  common.  The 
effusion  of  fluid  may  be  caused  by  the  altered  state  of  the  blood ; 
but  much  more  generally  it  is  owing  to  the  poison  producing  an 
acute  desquamative  nephritis  :  albumin,  tube-casts,  epithelial  cells,  and 
sometimes  blood,  are  found  in  the  scanty  urine;  and  we  meet  with 
severe  headache,  great  restlessness,  and  oedema  of  the  face  and 
extremities,  as  the  attending  symptoms.  Still,  notwithstanding  these 
grave  phenomena,  the  majority  of  the  cases  recover,  and  the  kidneys 
are  rarely  permanently  injured. 

The  dropsy  is  apt  to  show  itself  between  the  tenth  and  the  twen- 
tieth days  of  the  malady.  The  albuminous  condition  of  the  urine 
may  precede  it  by  several  days  ;  yet  dropsy  may  happen  without 
albuminuria,^  and  albumin  in  the  urine  is  not  always  associated  with 
dropsy.  In  most  cases  of  scarlatina  albumin  is' found  at  some  period 
of  the  disease  for  a  short  time  and  in  small  quantities. 

^  Gowers,  Diseases  of  the  Nervous  System. 

^  Gee,  in  Russell  Reynolds's  System  of  Medicine  ;  also  Quincke,  Berlin,  kliu. 
Woch.,  1882,  No.  27  ;  Dyce  Duckworth,  St.  Earth.  Hosp,  Rep.,  1883. 


FEVERS.  857 

The  state  of  exhaustion  noticeable  at  the  close  of  the  fever  and 
while  desquamation  is  still  going  on  is  at  times  great, — so  great  tliat, 
in  young  persons  especially,  the  case  wears  the  look  of  typhoid  fever. 
And  the  resemblance  is  heightened  by  the  occurrence  of  diarrlioea 
associated  with  a  swelling  of  the  solitary  and  agminated  glands. 
But  the  signs  of  desquamation,  the  sore  throat,  the  enlargement  of 
the  cervical  glands,  and  the  history  of  the  affection  furnish  distinctive 
marks  of  the  utmost  value.  We  must  also  bear  in  mind  that  an 
erythematous  rash  like  scarlatina  occurs  at  times  in  typlioid  fever 
preceding  the  characteristic  rose-spots. 

The  statements  that  have  just  been  made  concerning  the  diverse 
complications  of  the  malady  are  mainly  of  interest  on  account  of  their 
exhDDiting  the  inlricate  diagnostic  questions  tliat  may  arise.  Of  tlie 
recognition  of  the  disorder  during  the  febrile  stage  it  is  not  necessary 
to  say  much,  as  ordinarily  it  is  not  difficult.  The  distinction  between 
it  and  tlie  other  exanthematous  fevers  will  be  seen  by  glancing  at  the 
table,  to  which  a  place  is  elsewhere  assigned.  I  shall  only  here 
mention,  as  bearing  upon  the  differences  between  scarlet  fever  and 
measles,  that  cases  are  occasionally  encountered  in  which  the  erup- 
tion alone  is  too  ill  defined  to  become  the  sole  basis  of  an  opinion, 
and  that  then  we  have  to  lay  the  greatest  stress  on  the  presence 
or  absence  of  catarrhal  symptoms  and  sore  throat,  and  on  the  march 
of  the  symptoms.  So,  too,  with  reference  to  smallpox.  The  rash  pre- 
ceding the  formation  of  the  pustules  may  so  strongly  resemble  that  of 
scarlet  fever  that  a  scrutiny  of  all  the  attending  circumstances,  and  a 
careful  watching  of  the  eruption  for  at  least  a  day,  are  requisite  for 
the  detection  of  the  true  nature  of  the  case. 

An  erythematous  rash,  appearing  in  blotches  everywhere  except 
on  the  face,  has  been  noticed  in  laryngeal  diphtheria  after  the  opera- 
tion of  tracheotomy.^  But  it  is  very  irregular,  runs  a  rapid  course, 
and  is  not  followed  by  desquamation  ;  a  point,  it  may  be  here  men- 
tioned, distinguishing  all  the  forms  of  irregular  rashes  happening  at 
times — though  very  rarely — in  diphtheria,  from  the  scarlet  fever 
eruption.  As  the  result  of  gonorrhoea  we  may  have  symptoms  of 
a  low  fever  associated  with  a  cutaneous  rash  like  that  of  scarlet 
fever.  The  history  and  progress  of  the  case  chiefly  distinguish  this 
psc II do-scarlatina.'  The  same  is  true  with  reference  to  the  so-called 
surgkal  scarlet  fever.     It  shows  an  eruption  that  may  be  like  that  of 


'  Bericht  des  k.  k.  Krankoiihaiises.  Wciilcn.  ISGr). 

■'  Ballot,  Arch.  Gen.  de  Mo'-d.,  Sept.  1882.     The  same  author  rails  altnilioii  to  a 
l)uerperal  pseudo-ruheola,  a  false  measles,  from  Ijlood-infectiou. 


858  MEDICAL   DIAGNOSIS. 

scarlet  fever,  though  the  throat  symptoms  and  the  sequelae  are  lackmg. 
It  is  most  likely  of  septic  origin. 

Like  measles,  scarlatina  may  be  mistaken  for  rubella.  But  this 
really  resembles  measles  more  closely,  and  in  examining  it  presently 
the  differences  between  it  and  scarlet  fever  will  become  apparent. 

An  affection  with  several  features  like  scarlatina  is  breakbone  fever^ 
or  dengue.  The  points  of  dissimilarity  may  be  learned  by  referring  ta 
the  description  of  the  malady  already  given.  It  is  well  also  to  re- 
member that  certain  drugs.,  such  as  quinine  may  produce  a  scarlatini- 
form  eruption. 

Scarlet  fever  may  go  on  concurrently  with  other  fevers.  It  has 
been  observed  with  typhoid  fever,  with  varicella,^  and  with  small- 
pox.^ 

Measles. — The  symptoms  precursory  to  the  specific  eruption  of 
this  affection  are  fever,  watery  eyes,  frequent  sneezing,  flow  from  the 
nose,  and  cough  ;  in  fact,  all  the  manifestations  of  an  acute  coryza  or 
catarrh.  To  these  diarrhoea  is  in  many  instances  added,  indicating  a 
simultaneous  irritation  of  the  intestinal  mucous  membrane.  On  the 
fourth  day  after  the  beginning  of  the  morbid  signs,  a  rash  is  perceived 
on  the  face  and  neck  ;  thence  it  continues  to  extend,  until,  in  the 
course  of  two  or  three  days,  the  whole  body  is  covered."  The  tem- 
perature during  the  first  day  of  the  disease  is  generally  from  102°  to 
103°  ;  if  higher,  the  attack  is  likely  to  be  severe.  On  the  second  or 
third  day — usually  on  the  second,  when  it  may  be  but  98.6°  or  99° — 
it  is  markedly  lower,  and  it  rises  ag'ain  on  the  evening  of  the  third  or 
on  the  fourth  day  to  decided  fever  heat.  The  temperature  does  not 
at  once  decline  with  the  rash.  Indeed,  it  is  apt  to  go  on  rising  for 
twenty-four  to  thirty-six  hours  ;  the  occurrence  of  the  eruption  does 
not  alleviate  the  febrile  symptoms  ;  on  the  contrary,  while  it  is  spread- 
ing to  the  trunk  and  the  lower  extremities,  the  constitutional  disturb- 
ance lasts,  or  more  generally  increases.  But  as  soon  as  the  rash  has 
fully  reached  its  height,  the  defervescence  is  rapid ;  and  from  the  fifth 
to  the  seventh  day  of  the  disease  the  temperature  sinks  until  it  is  but 
little  above  the  norm.  By  the  ninth  day  of  the  disease  both  fever  and 
rash  have  left.  Frequently  then  the  cuticle  comes  away  in  fine  scales, 
and  this  desquamation  is  attended  with  very  annoying  itching.  The 
patient,  now  that  he  is  convalescent,  shows  his  illness :  he  is  pale  and 
somewhat  emaciated.  Often  he  still  coughs,  and  his  eyes  are  slightly 
inflamed.     These    signs    are    not    unusually  the    last    to    disappear. 

'  Church,  St.  Barthol.  Hosp.  Rep.,  1881  ;  Lond.  Med.  Record,  Nov.  1883. 
^  See  the  cases  of  Marson,  Medico-Chirurg.  Transact.,  vol.  xxx. 


FEVEBS.  859 

Paralysis,  of  cerebral,  spinal,  or  peripheral  origin,  may  occur  in  Uie 
sequence  of  measles/ 

Of  all  the  symptoms  mentioned,  two  are,  in  a  diagnostic  sense,  of 
pre-eminent  importance  :  the  catarrh  and  the  eruption. 

The  catarrh  is  nearly  constant.  It  is  true  that  a  variety  of  measles 
is  recognized, — "  rubeola  sine  catarrho  ;"  but  this  is  very  rare.  Gen- 
erally speaking,  the  coryza  and  catarrh  decline  with  the  eruption ; 
occasionally,  however,  they  remain  for  some  time  after  the  rash  has 
left.  The  feature  which  distinguishes  these  catarrhal  symptoms  from 
those  of  influenza  is  the  eruption :  before  this  happens,  the  diagnosis 
is  uncertain,  though  we  may  often  suspect  measles  by  the  look  of  the 
face,  the  greater  intensity  of  the  febrile  signs,  and  the  knowledge  that 
the  disease  is  prevailmg  in  the  community. 

The  erujAion  is  peculiar :  it  consists  of  slightly  raised  red  spots, 
which  coalesce  and  form  blotches  of  an  irregular,  crescentic  shape ; 
between  these  blotches  the  skin  is  of  natural  color.  The  eruption 
disappears  first  from  the  face ;  in  other  words,  it  disappears  in  the 
same  order  in  which  it  appears.  As  it  fades,  which  it  does  on  the 
third  or  fourth  day  of  its  appearance,  it  becomes  brownish,  and  sub- 
sequently of  a  yellowish  tint.  In  its  earliest  stages  it  is  similar  to  the 
papulae  of  smallpox ;  and  this  similarity  may  be  heightened  by  its 
being  mixed,  as  it  sometimes  is,  with  a  few  miliary  vesicles.  But  after 
the  first  day  of  the  rash  there  is  little  room  for  doubt.  In  the  one 
case  the  spots  remain ;  in  the  other,  they  change  into  pustules. 

A  very  valuable  contribution  to  the  diagnosis  of  measles,  especially 
to  its  early  diagnosis,  has  been  made  by  Koplik.^  He  has  pointed  out 
that  from  three  to  five  days  before  the  outbreak  of  the  eruption,  as 
well  as  to  be  seen  afterwards,  are  found,  when  the  mucous  membrane 
of  the  cheeks  and  lips  are  examined  by  strong  daylight,  and  limited 
to  them,  small,  irregular,  bright-red  spots  with  a  minute  bluish-white 
centre.  These  spots  are  most  frequent  opposite  the  lower  molar 
teeth,  and  they  are  not  met  with  in  any  other  exanthom,  or  in  any 
disease  of  the  skin. 

A  question  may  sometimes  arise  as  to  whether  the  eruption  be 
that  of  typhns  fever  or  of  measles.  Both  are  coarse,  both  often  not 
unlike  in  color,  and  both  may  be  developed  about  the  same  time. 
Generally  speaking,  however,  the  eruption  of  typhus  fever  shows 
itself  several    days    later   than  the  rash  of  measles ;    and,  although 


'  Allyn,  Medical  News,  Nov.  28,  1891,  p.  617  ;  Carpenter,  Medical  News,  Feli. 
13,  1892,  p.  183. 

■'  New  York  Med.  Record,  April  9,  1898. 


860  MEDICAL,  DIAGNOSIS. 

coarse,  it  is  not  crescentic,  and  is  found  on  the  trunk  and  extremities 
and  only  rarely  on  the  face.  Moreover,  the  physiognomy,  the  exces- 
sive prostration  of  strength,  and  the  marked  cerebral  symptoms  of  the 
low  fever  are  such  as  to  render  a  differential  diagnosis  seldom  difficult. 
From  hemorrhagic  measles  the  distinction  is  more  difficult ;  but  here, 
too,  the  absence  of  cerebral  symptoms  is  of  much  importance. 

Measles  is  usually  met  with  in  children  ;  but  it  may  be  encountered 
in  adults,  especially  among  soldiers,, and  is  in  adults  a  much  more 
severe  complaint  than  in  children.  In  the  latter  it  is  not  an  alarming 
disease.  Only  occasionally  does  it  occur  in  epidemics  which  present 
a  malignant  character.  Its  greatest  danger  commonly  consists  in  the 
eruption  disappearing  prematurely  or  appearing  but  partiahy,  and  in 
the  severity  of  the  thoracic  complications.  These  are  either  acute 
bronchitis  or  acute  pneumonia. 

Acute  bronchitis  may  occur  at  any  period  of  the  disorder,  and 
involve  the  finer  tubes.  But  it  does  not  generally  set  in  with  severity 
until  the  eruption  has  reached  its  height  or  is  beginning  to  fade.  In 
young  children,  symptoms  of  inflammation  of  the  larynx,  or  of  croup, 
are  at  the  same  period  apt  to  manifest  themselves.  Acute  pneumonia, 
too,  either  croupous  or  broncho-pneumonia,  the  latter  much  more 
often,  is  met  with  at  this  stage  of  the  malady,  or  sometimes  even  after 
convalescence  has  apparently  begun. 

Occasionally  the  thoracic  affection  leaves  a  chronic  bronchial  dis- 
ease, or  a  persistent  cough  and  night-sweats  point  to  tuberculosis.  It 
may  be,  in  individual  cases,  extremely  difficult  to  decide  Avith  which 
of  these  morbid  states  we  have  to  deal,  and  as  the  physical  signs  of 
tubercular  consumption  are,  in  children,  notoriously  ill  defined  and 
untrustworthy,  we  may  be  obliged  to  depend  upon  the  presence  or 
absence  of  tubercle  bacihi  before  coming  to  a  definite  conclusion. 

An  affection  formerly  very  common,  miliary  fever,  would  be  also  a 
source  of  much  confusion  were  it  in  our  day  often  encountered.  But 
epidemics  of  miliaria  are  now  extremely  rare.  Yet  we  know  that  it 
is  a  disorder  with  a  prodromal  stage  of  two  or  three  days,  during 
which  great  irritation  of  the  skin,  debility,  and  a  feeling  of  suffocation 
are  usual.  The  marked  disease  begins  with  profuse  sweating  and 
with  severe  fever,  and  praecordial  and  epigastric  distress.  These 
symptoms  last  until  the  appearance  of  the  rash,  generally  on  the  third 
or  the  fourth  day,  though  sometimes  not  until  much  later,  and  then, 
as  a  rule,  slowly  subside.  The  rash  appears  first  upon  the  neck  and 
the  breast,  and  consists  of  numerous  round  or  irregular  spots,  in  the 
centre  of  which  vesicles  arise  that  finally  burst  and  form  crusts.  The 
disease  ends  with  desquamation,  and  generally  in  a  slow  convales- 


FEVERS.  861 

cence.     The  sweating,  the  oppression  and  praecordial  pain,  and  the 
peciiKar  eruption  distinguish  this  epidemic  disease  from  measles. 

Rubella. — The  most  striking  resemblance  to  measles  is  furnished 
by  rubella.  This,  called  by  the  Germans  Bofheln,  and  often  spoken  of 
as  "  German  measles,"  is  not  a  hybrid  of  measles  and  of  scarlet  fever, 
but  a  special  exanthem,  which  occurs  in  epidemics.  It  displays  a  red 
eruption,  ushered  in  by  a  chill,  followed  by  slight  fever,  which  is 
accompanied  by  coryza,  cough,  and  sore  throat.  The  fever  lasts  for 
two  or  three  days  prior  to  the  eruption,  but  this  is  far  from  constant ; 
indeed,  it  often  does  not  last  more  than  half  a  day,  or  it  may  be  of  a 
week's  duration.^  The  temperature  rarely  exceeds  102.5°.  The  rash 
may  come  out  all  over  at  once,  or  spread  in  a  day  or  two  over  the 
body  ;  it  generally  appears  first  on  the  face  and  neck.  It  is  most  dis- 
tinct on  the  face,  the  scalp,  the  neck,  and  the  trunk,  being  more  scat- 
tered on  the  extremities  :  it  is  specially  distinct  about  the  mouth.  It 
first  resembles  measles,  but  the  spots  are  round  or  oval,  and  smaller 
and  paler,  and  they  soon  run  together  in  irregular  patches,  unlike  the 
well-defined  crescentic  eruption  of  measles  ;  they  show  no  tendency, 
however,  to  become  generally  confluent.  The  patches  are  of  variable 
size,  and,  unlike  the  rash  of  scarlatina,  are  surrounded  by  healthy 
skin  ;  small  spots  range  themselves  around  the  large  ones.  They  are 
of  deepest  color  in  the  centre,  but  not  bright-colored  as  in  measles, 
nor  of  the  dark  red  of  severe  scarlatina,  are  elevated,  and  very  much 
influenced  by  pressure.  The  eruption  lasts  ordinarily  four  or  five 
days,  but  in  severe  cases  eight  or  ten.  It  gradually  fades,  but  it  may 
happen  ^hat  it  fades  on  the  face  before  it  has  fairly  come  out  on  the 
legs,  and  desquamation  may  ensue,  though  the  scales  are  small,  and 
never  in  size  like  those  of  scarlet  fever.  During  the  continuance  of 
the  rash,  which  is  attended  with  much  itching,  the  general  symptoms 
are  greatly  aggravated,  except  the  fever,  which  indeed  may  be  percep- 
tible only  at  the  beginning  of  the  affection ;  the  sore  throat  and 
catarrh  may  be  severe,  and  attended  with  lioarseness  and  with  ina- 
bility to  swallow ;  there  are  congestion  of  the  conjunctiva  and  pain  in 
the  eyes.  Osborn  has  called  attention  to  enlargement  of  the  small 
glands  at  the  edge  of  the  hair  on  the  postero-lateral  sides  of  the  neck 
as  a  pathognomonic  sign."  As  the  rash  fades,  the  other  symptoms 
subside.  Swelling  and  even  suppuration  of  the  cervical  glands  are 
not  uncommon  sequelae. 

The  disease  may  be  very  difficult  to  distinguish  from  measles, 


'  Edwiirds,  article  "Rubella,"  in  Keating's  Cycl.  of  Diseases  n\'  Cliildivn. 
2  Weekly  Med.  Rev.,  Dec.  24,  1887. 


)2 


MEDICAL   DIAGNOSIS. 


except  when  it  is  epidemic  and  affects  those  who  have  already  had 
measles.  The  more  sudden  -onset,  often  almost  feverless,  the  milder 
course  of  the  complaint,  and  the  peculiarities  of  the  eruption  already- 
spoken  of,  are  guides  in  separating  individual  cases.  But  the  appear- 
ance of  the  rash  may  be  ill  defined  and  very  misleading.  The  fol- 
lowing table,  exhibits  the  differences  between  well-marked  cases  of 
rubella,  measles,  and  scarlet  fever : 


Rubella. 

Period  of  incubation  from 
nine  to  twenty-one  days  ; 
-   usually  eighteen  days. 

Premonitory  symptoms 
often  wanting,  but  fre- 
quently sore  throat.  If 
attack  severe,  loss  of 
appetite  and  drowsiness 
for  twenty-four  hours 
before  eruption. 

Eruption  is  mostly  the  first 
symptom ;  dots,  rosy- 
red,  with  well-defined 
edges,  first  behind  the 
ears,  on  scalp  and  face, 
around  mouth  ;  extends 
to  neck  and  chest ;  grad- 
ually covers  entire  body. 
Dots  coalesce  and  form 
patches. 

Fauces  look  dry,  with  a 
dark  mottled  red  hue  ; 
little  relation  of  appear- 
ance of  fauces  to  extent 
of  rash.  Sore  throat 
may  disappear,  to  recur 
in  last  stages  of  the 
disease. 


No  diazo-i'eaction  in  urine. 

Eyes  pink-red  and  suf- 
fused. 

Lymphatic  glands  gener- 
ally enlarged,  tender, 
hard,  notably  the  pos- 
terior cervical,  the  ax- 
illary, and  the  inguinal. 


Measles. 
Period  of  incubation  from 
seven  to  fourteen  days. 


Premonitory  symptoms 
common,  such  as  lassi- 
tude, loss  of  appetite, 
headache,  vomiting, 
watery  eyes,  catarrh, 
cough. 

Eruption  appears  on  fourth 
day  ;  first  behind  ears, 
then  on  scalp  and  fore- 
head ;  spreads  all  over 
face,  body,  and  limbs, 
forming  crescentic 
blotches.  Eruption  is 
papular  in  character  and 
dark-red  in  color  ;  never 
bright  rose-red. 

Fauces  red  and  swollen 
throughout  activity  of 
the  disease. 


Diazo-reaction. 

Eyes  red  and  watery  ; 
photophobia. 

Not  usually  affected  ;  the 
posterior  cervical  rarely 
and  slightly  ;  bronchial 
glands  always  enlarged. 


Scarlet  Fever. 

Period  of  incubation  from 
a  few  hours  to  seven 
days  ;  rarely  beyond  five 
days. 

Premonitory  symptoms ; 
usually  feeling  of  lassi- 
tude for  a  few  hours, 
frequently  vomiting.  If 
attack  slight,  patient 
complains  only  of  sore 
throat. 

Eruption  diffuse,  dusky 
red  with  interspersed 
raised  spots  ;  appears 
early  about  clavicles 
and  on  chest,  and  on 
covered  parts  of  the 
body  ;  intensely  hot  to 
touch. 


Fauces  vary  in  appearance 
from  slight  to  intense 
dusky  redness,  witli 
marked  swelling,  and 
sometimes  with  white 
spots  of  inspissated  se- 
cretion ;  intensity  bears 
direct  relation  to  skin- 
eruption.  Sore  throat 
throughout  disease. 

Eyes  unaffected. 

Lymphatic  glands  of  throat 
and  neck  at  first  scarcely 
discernible,  but  subse- 
quently enlai-ged. 


FEVERS. 


863 


Rubella. 
Catarrhal  symptoms  and 
cough  inconstant ;  there 
may  be  a  little  flaky  des- 
quamation ;  frequently 
none. 


Measles. 
Catari'hal  symptoms  and 
cough  constant  ;  a  little 
flaky  shedding  of  the 
epithelium,  varying  ac- 
cording to  the  intensity 
of  the  rash. 


Kidneys    rarely    affected  ;     Kidneys  not  affected. 

may  be  transient    trace 

of  albumin. 
No  diarrhoea.  Diarrhoea  frequent. 

Patient,  as  a  rule,  does  not     Usually  feels  illness  much. 

feel  ill. 

Tongue    clean    or   slightly     Tongue  slightly  furred, 
furred. 


Pulse  slightly  accelerated  ; 
maintains  ratio  to  tem- 
perature. 

Temperature  varies  be- 
tween 102°  and  103°. 


Pulse  usually  accelerated  ; 
maintains  ratio  to  tem- 
perature. 

Temperature  usually  from 

101°  to  103°. 


Infectiveness     lasts     from     Infectiveness  does  not  last 
ten  to  fourteen  days  if        for  more  than  from  four- 
disinfection  efficient.  teen  to  twenty  days,  if 
disinfection  efficient. 


Sequelae,  few  and  not  fre- 
quent ;  glandular  en- 
largements may  follow. 


Usually  complete  recovery 
in  two  weeks,  or  less. 


Sequela;,  bronchitis,  pneu- 
monia, pleurisy,  oph- 
tliahiiia.  otitis. 


Usually  complete  recovery 
in  two  weeks  ;  is  some- 
times followed  by  pro- 
longed period  of  ill 
iiealth. 


Scarlet  Fever. 

Catarrhal  symptoms  and 
cough  absent,  or  slight 
throat  cough.  Desqua- 
mation in  proportion  to 
the  extent  of  the  erup- 
tion ;  begins  as  this 
fades,  and  continues  for 
weeks ;  marked  about 
hands  and  feet. 

Kidneys  often  implicated  ; 
albuminuria ;  acute  ne- 
phritis common. 

Diarrhaea  not  uncommon. 

In  slight  cases  light  ill- 
ness ;  in  severe  cases 
grave  illness. 

Tongue  coated  with  a 
thick,  white  fur,  peeling 
from  the  tip  and  edges 
on  the  fourth  day,  leav- 
ing the  "strawberry" 
tongue. 

Pulse  greatly   accelerated, 

,  and  rapid  out  of  pro- 
portion to  temperature. 

Ranges  from  103°  to  106° ; 
proportionate  to  rash, 
but  not  to  pulse. 

At  onset  only  slightly  in- 
fective ;  is  very  infective 
after  first  forty-eight 
hours;  infectiveness 
may  continue  for  six  or 
eight  weeks  or  longer. 

Sequelae,  nephritis ;  en- 
largement or  suppura- 
tion of  submaxillary 
and  lymphatic  glands  ; 
otitis  ;  arthritis  ;  endo- 
carditis ;  epilepsy. 

Usually  complete  recovery  ;  ■ 
sometimes       prolonged 
convalescence    from   sc- 
(|U('la'  ;     mortality    high 
ill  I  111'  very  young. 


Tijplnin  fever ^  at  least  as  regards  tlic  eruption,  has  some  similarity 
to  German  measles.  But  the  severe  fever,  the  far  greater  gravity  of 
the  constitutional  symptoms,  the  rash  not  appearing  on  the  face,  and 


864  MEDICAL   DIAGNOSIS. 

the  absence  of  catarrhal  symptoms,  render  it  strikingly  unlike  the 
latter  affection. 

Rubella  is  contagious,  and  affects  especially  children ;  it  is  ex- 
tremely uncommon  after  forty  years  of  age.  Second  attacks  are  also 
very  rare.  It  does  not  protect  from  either  scarlet  fever  or  measles, 
nor  do  they  from  it. 

Smallpox. — Smallpox,  or  variola,  attacks  both  children  and 
adults.  It  is  a  highly  contagious  malady,  spreading  rapidly  among 
those  who  are  unprotected  by  vaccination.  The  period  of  incubation 
is  generally  about  twelve  days. 

The  chief  symptoms  of  the  stage  of  invcmon  are  chills,  fever,  vom- 
iting, pain  in  the  back,  and,  in  children,  convulsions.  The  fever  runs 
high,  and  exacerbates  markedly  towards  evening:  the  temperature 
may  reach  106°  or  more.  The  pain  in  the  back  is  severe,  particularly 
in  grave  cases  ;  it  may  be  attended  by  pain  in  the  limbs  like  those  of 
rheumatism  ;  there  are  also  intense  headache  and  restlessness.  All 
these  symptoms  subside  with  great  relief  at  the  end  of  the  third  or  on 
the  fourth  day,  when  an  eruption  shows  itself  on  the  lips  and  fore- 
head and  wrist,  soon  extends  to  the  trunk,  and  from  the  trunk  all 
over  the  body ;  with  the  appearance  and  the  spread  of  the  eruption 
there  is  a  gradual  but  very  decided  fall  m  temperature,  often  to  100.° 

At  first  the  eruption  has  the  appearance  of  papulae ;  but  on  the 
second  and  third  days  the  coarse  spots  undergo  a  decided  change. 
At  the  top  of  each  papule  appears  a  vesicle,  which  gradually  becomes 
larger,  and  fills  up  with  a  thick,  milky  fluid;  in  short,  becomes  a 
pustule.  By  the  fifth  or  sixth  day,  the  change  has  been  fully  accom- 
plished, and  the  pustules  are  spheroidal  and  lose  the  umbilicated  look 
which  they  had  while  forming.  During  all  this  time  the  temperature 
does  not  again  rise  ;  the  tongue  is  coated  and  swollen.  On  the  eighth 
day  pus  begins  to  ooze  from  the  edges  of  the  pustules,  and  a  secon- 
dary fever  sets  in,  lasting  for  three  or  four  days, — until,  indeed,  all  the 
pustules  are  broken ;  this  secondary  fever  is  sometimes  ushered  in 
by  a  chill ;  it  is  of  remittent  type,  and  the  evening  temperature  marks 
between  103°  and  105°.  There  is  gradual  and  protracted  deferves- 
cence ;  crusts  form  where  previously  there  had  been  pustules  :  and 
as  these  crusts  dry  and  fall  off,  the  skin  beneath  is  seen  to  be  of  a  red 
color,  that  only  slowly  fades,  and  here  and  there  are  noticed  those  scars 
and  pits  which  the  patient  carries  during  the  remainder  of  his  life. 

Preceding  the  characteristic  eruption  in  smallpox  a  red  rash  like 
that  of  scarlatina  may  be  noticed  in  the  pubic  and  the  inguinal  or 
lateral  thoracic  regions  ;  and  at  times  a  very  misleading  rash  of  measly 
form. 


FEVERS. 


865 


When  the  pustules  are  in  great  abundance,  they  run  together, 
constituting  confluent  smallpox.  The  eruption  may  be  discovered  a 
day  earlier  than  in  the  discrete  form,  and  the  rough,  red  blotches  are 
often  so  thickly  clustered  as  to  give  a  uniformly  red  aspect  to  the 
whole  surface.  When  the  pustules  completely  fill  up,  whole  por- 
tions of  the  face  or  of  the  trunk  seem  to  be  covered  by  one  extensive 


TemperatuiX'iii  the  severe  form  ol'  variola  ;  death  rluriiiu:  tlie  secomliiry  fever.    (After  Wuiulerlicli.) 


pustule,  which  gradually  dries  into  a  continuous  brownish  and  most 
disfiguring  crust.  While  the  process  of  maturation  is  going  on,  the 
features  are  observed  to  be  greatly  swollen  ;  the  eyes  may  be  hidden 
from  view;  the  nose  and  lips  arc  tumid;  conjunctivitis  is  not  un- 
common. The  patient  complains  of  the  tension  of  the  skin,  and  not 
infrequently  of  sore  throat  and  of  a  steady  flow  of  saliva  from  the 
mouth, — a  symptom  that  may  be  also  met  witli  in  measles.     The  sec- 

r,4 


866  MEDICAL   DIAGNOSIS. 

ondary  fever  is  violent,  far  more  so  than  in  discrete  variola.  It  may 
not  appear  until  a  day  or  two  Jater,  but  lasts  longer,  shows  a  higher 
temperature,  and  is  the  period  of  danger,  since  it  is  at  this  time  that 
death  is  most  apt  to  happen.  Before  death  the  temperature  is  some- 
times extraordinarily  high,  108°  or  upward. 

A  fatal  issue  is  often  preceded  by  a  dry  tongue,  by  delirium,  and 
by  great  restlessness  ;  by  what,  in  fact,  are  called  typhoid  symptoms. 
Sometimes  death  is  occasioned  by  attacks  of  dysentery  or  of  diar- 
rhoea, by  inflammation,  oedema  or  necrosis  of  the  larynx,  extensive 
pharyngitis,  by  acute  endocarditis,  or  by  plugging  of  a  vessel  in  the 
brain.  A  case  of  variola  has  been  reported  complicated,  during  con- 
valescence, by  convulsions,  followed  by  left  hemiplegia,  in  which  after 
death  an  area  of  softening  was  found  in  the  motor  area  of  the  right 
cerebral  hemisphere,  due  to  vascular  occlusion.^  Cases  of  variola 
have  also  been  observed  presenting  peripheral  neuritis  or  purulent 
peritonitis.^  Other  complications,  not  infrequently  fatal,  are  pleurisy 
and  broncho-pneumonia.  Sometimes  the  patient  sinks  at  the  onset 
of  the  disease.  In  these  malignant  cases,  mostly  met  with  at  the 
beginning  of  an  epidemic,  he  dies  from  the  virulence  of  the  poison. 
He  is  stupid,  delirious  ;  the  eruption  seems,  as  it.  were,  to  struggle  to 
reach  the  surface,  is  ill  defined  and  of  a  livid  hue,  and  may  fail  to 
appear  until  after  death.  Many  of  the  malignant  cases,  too,  are  of  the 
hemorrhagic  type,  marked  by  petechial  blotches  and  ecchymoses,  and 
profuse  hemorrhages  from  mucous  membranes.  The  specific  micro- 
organism of  smallpox  is  still  undiscovered. 

The  sequelae  of  smallpox  are  chronic  diarrhoea,  glandular  enlarge- 
ments, boils,  various  diseases  of  the  eyelids  and  eyeballs,  otitis  media, 
and  suppurative  arthritis.  Smallpox  is  occasionally  met  with  during 
the  progress  of  other  disorders,  blending  its  symptoms  with  those  of 
the  complaint  to  which  it  becomes  superadded.  It  is  thus  found  as 
an  intercurrent  affection  in  typhoid  fever,  in  typhus,  in  scarlet  fever, 
and  in  measles  ;  yet  even  then  there  is  no  difficulty  in  recognizing  its 
peculiar  traits, — its  lumbar  pain  and  characteristic  eruption.  Ordi- 
narily the  detection  of  variola  is  extremely  easy,  except  at  its  onset. 
But  the  points  of  similarity  it  may  present,  in  its  early  stages,  to 
typhus  fever,  and  to  several  other  diseases,  have  been  already  dis- 
cussed, and  need  not  be  repeated  ;  we  have  often  to  wait  the  course 
of  the  eruption  before  framing  a  positive  diagnosis  from  the  symptoms 
alone,  and  without  taking  into  account  the  epidemic  influences  pre- 

^  Davezac  and  Delmas,  Journal  de  Medecine  de  Bordeaux,  1893,  No.  38.  p.  421. 
2  Auche,  Bulletin  Medical,  Jnn.  25,  1893. 


FEVERS. 


867 


Fig.   84. 


vailing.  When  the  disease  is  fully  developed,  all  difficulty  in  its  diag- 
nosis ceases.  In  the  period  of  invasion  the  pain  in  the  loins  is  the 
most  significant  differential  sign.  It  is  by  this  alone  that  we  may  be 
enabled  to  tell  the  scarlatiniform  rash  or  the  measly  rash  that  is  some- 
times found  to  precede  the  papules  of  smallpox ;  though  these  initial 
rashes  are  generally  much  more  localized  and  not  so  widely  diffused 
as  those  of  real  scarlet  fever  or  measles,  and  the  bastard  scarlatina 
has  not  the  vivid  hue  of  the  true  dis- 
ease, nor  the  measly  rash  the  coarse 
ness  and  hardness  of  the  papule  of 
smallpox. 

The  contagion  of  smallpox  does  not 
always  manifest  itself  by  an  attack  of 
variola.  Sometimes  it  is  modified  by 
happening  in  a  person  who  is  partially 
protected  by  vaccination.  This  vario- 
loid disease  is  mild  and  very  rarely 
fatal :  it  protects  against  smallpox.  It 
is  distinguished  from  variola  by  the 
pustules  passing  more  quickly  through 
all  their  stages,  and,  above  all,  by  an 
absence  of  secondary  fever.  Soon  after 
the  eruption — within  thirty-six  hours — 
the  thermometer  shows  freedom  from 
fever,  and,  unless  serious  complications 
happen,  the  temperature  remains  nearly 
normal.  The  suppuration  is  far  less 
deep  ;  and  the  resulting  cicatrices  are 
often  scarcely  discernible. 

Varicella. — A  specific  disorder  simi- 
lar to  but  not  identical  with  variola  or 
varioloid  is  chicken-pox,  or  varicella. 
It  differs,  as  regards  its  symptoms,  from 
smallpox  in  the  leniency  of  the  intro- 
ductory fever  ;  in  the  eruption  beginning 
generally  first  on  the  trunk,  occurring 

often  on  the  second  day,  though  it  may  not  sliow  itself  until  the  end 
of  the  third,  and  continuing  to  appear  and  disappear  in  crops,  the  mass 
of  the  eruption,  however,  having  become  evident  within  twenty-four 
hours ;  in  the  vesicles  being  surrounded  by  little  or  no  inflammatory 
redness  ;  in  their  remaining  vesicles  and  not  becoming  pustules ;  in 
their  attaining  their  height  on  the  third  or  fourth  day  of  llie  eruption, 


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iiifr  ill  recovery  :  the  ahseiieeof  second- 
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dei'licli.  I 


MEDICAL   DIAGNOSIS. 

and  then  bursting  and  shrivelling  without  presenting  depressions  at 
their  apices  ;  and  in  the  crust  that  falls  off  about  five  days  subsequently 
being  followed  by  a  smooth,  shining,  round,  and  irregular  pit.  Then 
the  eruption  is  rarely  prominent  on  the  face  ;  and  the  disease  does  not 
protect  from  a  subsequent  attack  of  variola.  Sometimes  the  vesicles 
may  be  found,  as  are  the  pustules  of  smallpox,  on  the  roof  of  the 
mouth  and  at  the  back  of  the  throat.  But,  although  they  may  be 
everywhere  plentiful,  the  disorder  is  not  a  grave  one.  Still,  I  have 
known  it  in  one  instance  to  terminate  fatally.  Spivak  ^  has  described 
a  case  of  gangrene  of  the  scrotum  that  followed  varicella. 

Erysipelas. — This  disease,  as  the  physician  sees  it,  is  mostly 
confined  to  the  head  and  face.  It  may  or  may  not  be  preceded  by  a 
scratch  or  an  abrasion.  It  is  an  eruptive  fever  beginning  with  a  chill. 
Soon  a  portion  of  the  face  is  noticed  to  be  red  and  hot.  The  redness 
spreads,  a  clearly  defined  edge  marking  its  onward  march  ;  and  gen- 
erally it  does  not  stop  until  it  has  occupied  the  whole  of  the  face  and 
a  considerable  portion  of  the  scalp.  The  features  are  then  so  tume- 
fied as  to  be  hardly  recognizable.  The  patient  is  very  restless,  has 
high  fever,  and  not  infrequently  enlargement  of  'the  glands  at  the 
angle  of  the  jaw  and  sore  throat.  By  the  seventh  or  eighth  day  the 
disease  is  over,  and  large  patches  of  cuticle  fall  from  the  countenance 
no  longer  swollen  and  disfigured.  The  temperature  remains  high  for 
a  few  days,  with  decided  evening  exacerbations,  and  then  falls,  not  to 
rise  markedly  again. 

This  is  simple  erysipelas  ;  but  the  affection  may  extend  from  the 
true  skin  to  the  subcutaneous  areolar  tissue,  and  give  rise  there  to 
collections  of  pus,  which  reveal  their  presence  by  chills  and  an  ob- 
scure sense  of  fluctuation,  and  keep  up  an  irritative  fever  until  they 
are  discharged.  Irrespective  of  this,  the  tumefaction  is  much  greater 
in  this  phlegmonous  variety  of  the  malady,  and  there  is  more  constitu- 
tional disturbance  ;  but,  on  the  other  hand,  the  morbid  action  travels 
less  rapidly,  and  often  remains  more  circumscribed.  In  some  cases 
the  specific  inflammation  extends  to  the  brain,  and  instead  of  wan- 
dering at  night,  always  a  common  symptom,  we  have  violent  delirium, 
soon  succeeded  by  coma  and  rapid  sinking.  In  other  cases,  and  they 
are  by  far  the  most  frequent,  we  may  find  these  active  cerebral  symp- 
toms and  yet  not  be  able  to  detect,  after  death,  signs  of  inflammation 
of  the  brain  or  its  membranes, — the  cerebral  symptoms  are  the  result 
of  the  toxsemia.  Now  and  then  the  disorder  passes  to  the  throat, 
reaches  the  larynx  and  bronchial  tube,  and  places  life  in  imnnnent 

^  Medical  News,  March,  1895. 


FEVERS. 


869 


peril  from  cedema  of  the  glottis,  or  from  a  hazardous  form  of  capillary 
broncliitis.  In  some  instances  a  highly  asthenic  state  becomes  devel- 
oped, and  the  patient  dies  exhausted. 

Internal  lesions  happen  not  infrequently  in  erysipelas.  I  have 
found  the  urine  albuminous  in  the  great  majority  of  instances.' 
Heart-murmurs  are, not  unusual,  and  are  said  to  depend  upon  endo- 
carditis, which  is  doubtful,  though  ulcerative  endocarditis  may  be  met 


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Temperature-chart  in  a  case  of  facial  erysipelas,  seen  soon  after  outbreak  of  the  disease. 

with.  Friedreich  speaks  of  swelling  of  the  spleen  being  of  com- 
mon occurrence.  The  disease  often  manifests  a  distinct  tendency  to 
recur.  The  contagious  inflammation  of  the  skin  is  caused  by  the 
streptococcus  erijsipelatis,  also  called  after  Fehleisen,  who  has  specially 
described  it.  The  disease  may  set  in  with  convulsions,^  or  convulsions 
happen  in  its  course  from  uraemia.-^ 

The  diagnosis  of  erysipelas  is  not  beset  with  ditliculties.  Ery- 
thema resembles  it  closely;  in  erythema  there  is  no  swelling,  not 
much  tendency  to  spread,  and  almost  no  constitutional  disturbance. 
The  ordinary  exanthematous  fevers,  at  an  early  stage,  may  be  mistaken 
for  erysipelas.     But  all  of  them,  even  scarlatina,  have  a  longer  period 


'  On  the  Internal  Complications  of  Acute  Erysipelas.  Aiiier.  Journ.  Med.  Sci., 
Od.  1877. 

-  Case  of  Eslinor's.  M<'iuphis  Lancet.  1899. 
'  Case  seen  with  Saliiijier.  and  reported  l)y  iiiiii. 


870  MEDICAL   DIAGNOSIS. 

of  febrile  invasion  ;  in  all,  too,  although  the  eruption  takes  its  origin 
at  one  spot,  and  generally  on  the  face,  it  is  not  limited  there.  The 
thickly-clustered  blotches  of  beginning  confluent  smallpox  give  at  times 
to  the  face  the  look  of  erysipelas.  Yet  here,  also,  evidences  can  be 
found  of  a  rash  about  to  appear  all  over  the  body  ;  and  doubt  is  soon 
dispelled  by  the  progress  of  the  eruption.  Sometimes  vesicles  and 
even  irregular  pustules  form  in  erysipelas,  and  the  malady  may  be 
looked  upon  as  a  chronic  disease  of  the  skin,  such  as  eczema,  pem- 
phigus, or  impetigo  ;  but  these  affections  lack  the  history  of  a  recent 
acute  disease,  and  in  reality  the  likeness  is  not  a  striking  one.  The 
closest  similarity  is  to  herpes  zoster  of  the  forehead  and  face.  But 
the  eruption  in  this  does  not  pass  the  middle  line.^  The  red  color  of 
the  skin,  the  fever,  and  the  absence  of  colic  and  of  gastro-intestinal 
attacks,  distinguish  erysipelas  from  the  transient  but  recurring  swell- 
ings of  angeio-neurotic  oedema. 

Erysipelas  may  break  out  in  one  part  of  the  body. after  another 
and  the  disease  be  thus  kept  up  for  a  long  period.  This  erysipelas 
migrans  runs  its  course  more  rapidly  and  completely  in  one  part  than 
in  another,  and  in  accordance  w^ith  a  general  law  which  it  obeys.' 

Erysipelas  may  be  confounded  with  mumps.  The  error  is  mainly 
caused  by  stress  being  laid  on  the  redness  which  is  frequently  found 
beneath  one  or  both  ears  in  parotitis,  but  which,  unlike  erysipelas,  is 
attended  with  much  pain  on  moving  the  jaw,  and  with  decided  glan- 
dular tumefaction.  The  redness,  moreover,  shows  no  tendency  to 
spread,  and  rarely  continues  for  the  four  or  five  days  during  which 
mumps  lasts.  In  very  young  children,  however,  there  may  be  some 
difficulty  in  diagnosis.  I  have  seen  the  glands  at  the  angle  of  the 
jaw  swollen  for  one  or  two  days  prior  to  the  discoloration  over  them 
taking  on  an  erysipelatous  blush,  which  then  spread  rapidly,  and 
became  associated  with  swelling  of  the  glands  of  the  other  side.  The 
glandular  complaint  was  the  complication  of  erysipelas. 

A  fever  with  a  distinct  pharyngitis  as  a  local  manifestation,  the  so- 
called  pjharyngeal  fever,  is  probably  an  epidemic  erysipelatous  fever  of 
light  type.  It  has  been  particularly  described  by  Austin  Flint.  Roches- 
ter,^ and  Harvey  E.  Brown.*  The  fever  lasts  from  three  to  six  days, 
and,  besides  the  marked  pharyngitis,  is  attended  with  swelling  of  the 
lymphatic  glands  of  the  neck,  accompanied  by  pain.  The  disease 
shows  a  proportion  of  cases. with  erysipelas  of  the  face. 

^  Fagge,  Practice  of  Medicine,  vol.  i.  p.  271. 

^  Traced  by  Pfliiger  in  70  cases  ;  quoted  in  Schmidt's  Jahrb.,  Xo.  7,  1873. 

•■*  Buffalo  Medical  Journal.  1857. 

*  Flint's  Principles  and  Practice  of  Medicine. 


CHAPTER    XIII. 

DISEASES    OF   THE   SKIN. 

To  facilitate  the  discrimination  of  diseases  of  the  skin,  they  have 
been  grouped  into  classes.  An  extensively  used  system  of  classifi- 
cation takes  for  its  basis  the  anatomical  seat  and  arrangement  of  the 
cutaneous  malady  :  it  is  that  of  Hebra.  As  developed  by  him,  it 
is,  however,  not  a  purely  anatomical,  but  a  mixed  system,  resting 
largely  on  a  pathological  basis.  Similar  is  the  classification  of  the 
American  Dermatol ogical  Association.  All  diseases  of  the  skin  are 
arranged  in  eight  classes :  Disorders  of  the  Glands,  sweat  and  seba- 
ceous ;  Inflammations ;  Hemorrhages ;  Hytertrophies,  of  pigment, 
epidermal,  and  papillary  layers,  and  of  connective  tissue  ;  Atrophies, 
of  pigment,  hair,  nail,  and  cutis  ;  New  Growths,  of  connective  tissue, 
vessels,  and  granulation-tissue ;  Neuroses ;  and  Parasitic  Affections, 
vegetable  and  animal.  Whatever  classification  we  adopt,  when  a  dis- 
ease of  the  skin  is  presented  for  examination  we  generally  first  en- 
deavor to  ascertain  the  special  group  it  belongs  to  ;  for  instance,  is  it 
macular,  papular,  vesicular,  or  pustular,  or  does  it  present  lesions 
representing  more  than  one  group  ?  Having  determined  this,  we 
next  fix  which  member  of  the  group  it  is,  and  then  regard  its  precise 
seat,  and  its  pathological  causation.  When  this  has  been  accom- 
plished, we  inquire  into  the  history  of  the  affection  and  its  duration, 
whether  acute  or  chronic ;  take  into  account  the  general  condition  of 
the  patient;  search  for  the  evidences  of  a  cachexia  or  of  some  visceral 
disturbance, — a  study  the  importance  of  which  is  as  great  as  that  of  the 
recognition  of  the  cutaneous  malady  ;  and  trace,  as  far  as  possible, 
tlie  cause  of  llie  disorder,  hi  many  inshuices  uiicroscopical  and  bac- 
teriological examination  will  l)e  nt'cessary  to  siippiiMnent  the  clinical 
evidence  and  complete  the  diagnosis. 

Here  is  a  table  in  which  cutaneous  arreclious.  oniilling  some  of 
the  less  important  ones,  are  grouped  according  to  their  most  obvious 
features,  as  well  as  according  to  their  pathological  bearings: 

871 


872 


MEDICAL   DIAGXOSIS. 


Diseases  of  the  Skix. 


Inflammatory. 


Erythematous  Diseases 


Papular  Diseases 


Vesicular   Diseases 


Bullous    Diseases 


Pustular  Diseases 


.  Squamous    Diseases 


Macule  ;  Pigmentary  Changes 


Hypertrophies  of  Special    Textures 


Atrophies 


Parasitic  Diseases 


Initial  rashes  of  eruptive  fevers. 

Erythema. 

Roseola. 

Urticaria. 

Papular  eczema. 

Lichen. 

Prurigo. 

Eczema. 

Herpes. 

Dermatitis  herpetiformis. 

Pemphigus. 

Hydroa. 

Acne. 

Boils,  or  Furuncle. 

Sycosis  non-parasitica. 

Impetigo. 

Ecthyma. 

Rupia. 

Glanders. 

Psoriasis. 

Pityriasis. 

Ichthyosis. 

Squamous  eczema. 

Melasma. 

Ephelides. 

Vitiligo. 

Chloasmata. 

Na3vi . 

Purpura  simplex. 

Xanthoma,  or  Xanthelasma. 

Elephantiasis  Arabum. 

Scleroderma. 

Keloid. 

Dermatolysis. 

Warts,  Corns,  etc. 

As  of  the  Hair  ;  the  Xails. 

Senile  Atrophy. 

Scabies. 

Phtheiriasis. 

Favus. 

Anthrax. 

Tuberculosis. 

Molluscum  epitht'liale. 

Lepra. 

Mycetoma. 

Actinomvcosis. 


DISEASES  OF  THE  SKIN. 


87.3 


Parasitic.  Disease^ 


I 


New   Growths < 


f  of  Sebaceous 
Glands  .  . 


Altered  G land-Secretion J 


Diseases  of  the  Skin.  —  Continued. 

r  Tinea  sycosis,  or  Mentagra. 
Tinea  circinata. 
Tinea  tonsurans. 
Tinea  decalvans. 
Tinea  versicolor,  etc. 
Cancer. 
Sarcoma. 

Molluscuiu  fihrosuia. 
Lupus. 
Leprosy,  etc. 
Seborrhoea. 
Comedo. 
Sebaceous  cyst. 
Hyperidrosis. 
Anidrosis. 
<^   Chromidrosis. 
Bromidrosis. 
Miliaria,  etc. 
Hyperaesthesia. 
Anaesthesia. 
Pruritus. 
Neuroma. 

Nervous   Affections ^    Dermatitis  herpetiformis. 

Herpes  zoster. 
Peliosis  rheumatica. 
Plica  polonica. 
Alopecia  areata. 


of  Sweat- 
Glands 


,,  i:,         .  f  Syphilodermata. 

Lonstitltional  bKiN  Affections ]      ^^ 

I  Scrofulodermata, 


etc. 


Most  diseases  of  the  skin  are  again  subdivided  into  several 
varieties,  based,  for  the  most  part,  on  their  duration,  situation,  form, 
feel,  and  color.  Thus,  we  have  constantly  recurring  the  terms  fugax, 
inveterata,  capitis,  facialis,  palmaris  ;  guttata,  when  like  a  drop  on  the 
skin  :  nummularis,  when  like  a  coin  ;  larvalis.  like  a  mask  ;  the  qual- 
ifying words  leeve,  induratum  ;  circinatum,  annulatum,  marginatum, 
indicating  configuration,  and  the  adjectives  of  color,  nigrum,  rubruni, 
versicolor.  But  these  divisions  are  all  of  secondary  importance  ;  and 
in  this  outline  not  much  regard  will  be  paid  to  them.  Premising  this 
statement,  let  us  briefly  examine  the  characteristics  of  the  various 
cutaneous  affections  of  more  common  form,  beginning  with  those  of 
inflammatory  origin. 

Erythematous  Diseases. — There  are  only  three  affections 
which,  strictly  speaking,  come  under  this  division  of  cutaneous  com- 
plaints :  erythema,  roseola,  and  urticaria,     In  all  of  these  the  skin  is 


874  MEDICAL  DIAGNOSIS. 

more  or  less  red,  and  its  surface  unbroken  ;  the  hypergemia  affects 
chiefly  the  papillary  layer.      ** 

Mythema. — This  is  characterized  by  a  uniform  and  continuous 
redness  of  the  skin,  occurring  in  irregular  patches  of  some  size,  at- 
tended with  burning,  and  with  but  slight,  if  any,  swelling,  and  dis- 
appearing without  desquamation  or  mark  or  scar.  The  eruption 
is  chiefly  found  on  the  back  of  the  hands,  the  forearms,  the  legs, 
and  the  face  and  neck  ;  rarely  on  the  trunk.  There  is  little  or  no 
itching.  The  affection  may  be  due  to  the  action  of  heat  or  cold,  or  of 
irritants  ;  or  it  may  be  connected  with  some  visceral  abdominal  dis- 
order. It  is  usually  acute.  There  is  only  one  variety  apt  to  be  com- 
bined with  decided  constitutional  or  febrile  symptoms, — the  hard, 
painful,  reddish  protuberances  most  .commonly  seen  on  the  legs,  and 
constituting  the  so-called  erythema  nodosum.  This  form  of  the  com- 
plaint, in  which  there  is  a  serous  effusion,  is  chiefly  observed  in  those 
of  rheumatic  diathesis,  and,  unlike  the  simple  erythema  and  the  ery- 
thema intertrigo,  which  are  mere  hypersemias,  is  classed  with  the  exu- 
dations or  inflammations'.  All  the  exudative  forms  of  erythema  may 
be  grouped  under  the  title  of  erythema  multiforme,  the  varieties  of 
which  are  the  papular,  bullous,  and  nodose,  the  lesions  appearing 
principally  on  the  backs  of  the  hands  and  feet. 

There  is  a  desquamative  fo^-m  of  erythema  resembling  scarlet  fe"\'er, 
attended  with  fever  of  a  few  days'  duration,  with  epistaxis,  and  show- 
ing an  extraordinary  tendency  to  relapse.  The  eruption  is  uniform 
and  intensely  red,  and  there  is  no  sore  throat,  or  there  is  mere  red- 
ness of  the  fauces.  Erythema  solare,  or  superficial  dermatitis  following- 
exposure  to  the  sun's  rays,  is  usually  fohowed  by  free  desquamation. 

A  chronic  form  of  erythema  results  from  pressure,  or  the  rubbing 
together  of  folds  of  skin,  the  erythema  intertrigo  ;  a  slight  discharge  may 
coat  the  rubbed  surface.     It  is  liable  to  acute  exacerbations. 

Roseola. — This  term  is  applied  to  circumscribed  spots  of  a  rose-red 
color  and  of  a  more  or  less  circular  form.  The  spots  are  smaller  than 
those  of  erythema  simplex.  In  erythema  congestivum,  or  roseola,  there 
is  slight  fever,  and  at  times  redness  of  the  fauces.  The  afl'ection  often 
exists  in  connection  with  a  derangement  of  the  stomach,  or  with 
rheumatism,  is  frequent  in  summer  and  in  autumn,  is  generally  acute, 
and  bears  a  certain  resemblance  to  scarlatina  and  to  measles  ;  but  it  is 
not  contagious,  its  constitutional  symptoms  are  much  milder,  the  rash 
is  rosy,  not  crescentic,  nor  present  over  the  whole  body,  and  we  thid 
neither  the  marked  sore  throat  of  scarlet  fever  nor  the  catarrli  of 
measles.  A  rose-rash  occurs  in  the  course  of  typhoid  fever,  and  there 
is  also  a  syphilitic  form. 


DISEASES  OF  THE  SKIN.  875 

Urticaria. — Nettle-rash  gives  rise  to  prominent  and  ijcrtrctly  smootli 
patches,  tlie  color  of  which  is  either  redder  or  whiter  than  the  sur- 
rounding skin  ;  the  white  wheals  may  be  surrounded  by  a  red  border. 
The  wheals  are  generally  small,  but  they  may  be  of  the  size  of  the 
palm.  The  eruption  is  fugitive  and  capricious,  is  attended  with  more 
itching,  burning,  and  tingling  than  the  other  exantliemata,  and  is  much 
more  evanescent,  generally  disappearing  in  two  days  at  farthest.  It 
may,  however,  exist  in  a  chronic  form,  the  wheals  coming  out  in  con- 
stant succession,  especially  after  scratching  or  other  irritation  of  the 
surface.  Pigmentation  occurs  in  the  variety  know^n  as  urticaria  pig- 
mentosa. 

The  cause  of  urticaria  is  irritation  of  the  gastro-intestinal,  pulmo- 
nary, or  urinary  mucous  membrane.  Certain  kinds  of  lish,  especially 
shell-fish,  are  particularly  prone  to  produce  it ;  so  do  mushrooms  and 
strawberries.  At  times  it  is  due  to  menstrual  disorders,  or  to  sudden 
emotion,  or  to  the  excessive  use  of  mineral  waters,  or  to  antipyrln. 
It  may  be  secondary  to  the  itch,  or  to  phtheiriasis.  It  occurs  in  cere- 
bro-spinal  fever,  and  is  common  in  dengue,  especially  in  children.^ 

Urticaria  is  most  probably  a  reflex  phenomenon,  caused  chiefly  by 
reflected  irritation  to  the  cutaneous  vasomotor  nerves.  Urticaria 
resembles  erythema  nodosum ;  but  there  is  no  itching  in  the  latter 
affection,  which  is  chiefly  found  in  the  lower  limbs,  and  the  swellings 
change  like  bruises. 

Papular  Diseases. — A  papule,  or  pimple,  is  a  small  elevation  of 
the  cuticle  with  an  inflamed  base ;  it  does  not  contain  fluid,  and 
usually  terminates  in  desquamation.  It  results  from  a  small  amount 
of  lymph  or  a  newly  formed  growth  in  the  derm  itself. 

Lichen. — This  furnishes  the  best-marked  example  of  a  papular 
eruption.  It  consists  of  minute  conical  papulae,  generally  of  reddish 
color,  and  occurring  in  clusters.  It  is  most  frequently  encountered  in 
the  summer  months  and  in  adults,  and  often  in  persons  who  have 
been  exposed  to  much  fatigue  or  anxiety.  Sometimes  it  is  evidently 
connected  with  disordered  digestion.  It  is  usually  chronic.  There 
is  often  a  mixture  of  papulae  with  an  eczematous  eruption.  Prickly 
heat,  or  lichen  tropicus,  frequently  exhibits  also  sudamina. 

In  the  lichen  ruber  of  Hebra  the  red  papules  are  of  the  size  of  the 
head  of  a  pin ;  they  spread  by  peripheral  growth,  are  flat,  irregular, 
and  have  a  glazed  look  and  very  slight  scales  ;  there  is  considerable 
itching.  The  disease,  which  is  an  inflammatory  one,  is  chronic  ;  its 
common  site  is  on  the  forearm.     It  resembles  psoriasis,  but  at  the 


1  J.  C.  Wilson,  Treatise  on  the  Continued  Fevers,  1881. 


876  -  MEDICAL   DIAGNOSIS. 

edge  of  the  patch  are  the  characteristic  papules.  Poor  nutrition  and 
nervous  exhaustion  are  its  main  causes. 

In  the  lichen  scrofulosorum  the  eruption  consists  of  httle  pale 
papules,  which  are  chiefly  found  on  the  trunk.  There  is  no  itching ; 
but  we  find  marked  signs  of  scrofula. 

The  lesions  of  lichen  planus  are  small,  hard,  red  papules,  that  may 
be  umbilicated  and  coalesce  into  patches.  In  the  latter  case  scaling 
occurs,  and  more  or  less  itching  is  a  frequent  accompaniment.  The 
smallness  of  the  recent  lesions,  which  are  at  first  of  the  same  color  as 
the  surrounding  skin,  the  flat  glazed  tops  of  the  older  papules,  the 
pure  white  color  of  the  silvery  scales,  which  are  not  heaped  up,  and 
the  unsymmetrical  character  and  distribution  of  the  patches,  none  of 
which  are  circular,  mil  serve  to  distinguish  this  from,  psoriasis.  Papu- 
la/- eczema  has  its  lesions  in  groups  upon  an  inflamed  base,  and  vesicu- 
lation  and  desquamation  occur. 

Prurigo.— This  is  characterized  by  a  papular  affection  of  the  skin 
attended  with  excessive  itching.  It  is  a  very  rare  disease  in  this 
country.^  The  pimples  are  generally  torn  by  the  finger-nails,  and  are 
surmounted  by  black  scabs.  They  are  not  red,  as  those  of  hchen 
usually  are,  and  are,  as  a  rule,  larger,  and  accompanied  by  much 
more  pruritus  and  by  thickening  of  the  skin.  The  affection  may  or 
may  not  be  attended  with  constitutional  symptoms.  It  is  very  ob- 
stinate, especially  when  happening  in  old  persons.  It  generally  affects 
the  legs,  the  arms,  and  the  trunk,  rarely  the  face  and  the  neck,  never 
the  palms  and  the  soles.  The  skin  of  the  anterior  and  outer  part  of 
the  leg  is  most  changed ;  that  over  the  flexors  in  the  forearm  is  always 
healthy.  The  distressing  disorder  may  be  purely  local,  occurring 
around  the  anus,  or  on  the  scrotum  and  the  root  of  the  penis,  or  on 
the  pudenda.  Some  of  these  cases,  however,  though  called  prurigo, 
present  no  papulse,  and  the  disorder,  is  due  to  perverted  sensibility 
of  the  cutaneous  nerves  alone,  and  is  really  a  pruritus.  Prurigo  is 
often  attended  with  eczema. 

Many  supposed  instances  are  not  really  prurigo,  but  phtheiriasis, 
due  to  the  irritation  of  body-lice,  that  produce  papules,  whose  apices 
are  scratched  off  and  show  little  points*  of  dried  blood.  True  prurigo 
is  frequently  found  to  be  connected  with  deterioration  of  the  health, 
and  is  chiefly  met. with  among  the  poor  and  the  neglected.  It  may 
last  a  lifetime,  beginning  in  childhood.  Its  local  forms  are  associated 
with  irritation  of  the  bladder,  the  rectum,  or  the  uterus. 

Papules  and  tubercles,  or  large  papules,  occur  in  the  latter  stages  of 


^  Only  34  cases  in  123,746  of  skin-disease  :  Van  Harlingen  on  Skiii-Diseases. 


DISEASES  OF  THE  SKIN.  877 

syphilis ;  they  are  often  preceded  by  the  pigmented  erythematous 
syphiloderm.  Gumma  is  a  tertiary  manifestation,  mostly  appearing  in 
the  subcutaneous  or  submucous  connective  tissue  without  inflamma- 
tion, irritation,  or  itching,  the  lesions  ultimately  attaining  a  considera- 
ble size.  At  first  the  color  of  the  skin  is  not  changed,  but  finally  it 
becomes  deeply  congested  and  glazed,  and  as  the  contents  of  the 
lesion  soften,  the  overlying  skin  breaks  down,  and  the  purulent  ma- 
terial is  discharged. 

Vesicular  Diseases. — These  are  characterized  by  an  effusion  of 
a  clear  or  a  sero-purulent  fluid  beneath  the  epidermis,  wdiich  is  gener- 
ally raised  in  small  elevations.  To  the  class  of  vesicular  diseases 
belong  especially  eczema  and  herpes. 

Eczema. — The  malady  consists  of  minute  vesicles  collected  together 
in  irregular  patches.  The  vesicles  are  often  confluent,  and  it  then  ap- 
pears as  if  the  whole  surface  were  secreting  fluid.  This  may  harden, 
from  exposure  to  the  air,  in  scabs  of  various  thickness  and  color. 
The  skin  itself  is  often  of  a  vividly,  red  hue ;  indeed,  it  is  inflamed. 
and  a  new  cell-growth  takes  place  both  in  the  rete  mucosum  and  in 
the  papillary  layer  of  the  derm.  It  is  there  that  the  effusion  of  serum 
begins.     In  chronic  cases  the  inflammatory  infiltration  extends  deeper. 

Eczema  is  the  most  common  of  all  the  cutaneous  maladies  ;  but 
it  is  not  contagious.  It  may  .affect  the  whole  body,  yet  is  ordinarily 
limited  to  some  portion  of  it.  It  is  acute  or  chronic.  The  former  is 
generally  seen  as  the  effect  of  local  irritants,  and  may  be  met  with  in 
young  and  healthy  persons.  Chronic  eczema  is  more  usual,  is  often 
the  consequence  of  constitutional  disturbance,  and  is  frequently  found 
to  be  associated  with  some  disorder  of  the  digestive  system.  It  has 
as  a  frequent  seat  the  flexor  surfaces  of  the  limbs.  Dentition  and  un- 
healthy milk  are  common  sources  of  the  affection  in  very  young  chil- 
dren. In  them  the  disease  is  extremely  apt  to  attack  the  scalp  and 
face,  forming  the  complaint  often  described  as  "  crusta  lactea ;"  or  if 
the  secretion  be  partly  purulent,  or  early  become  so,  and  dry  into 
large,  dark  scabs,  the  malady  is  designated  as  eczema  impeUginode.^. 
This  is  most  often  met  with  in  scrofulous  subjects.  There  is  less  heat 
and  itching  than  in  other  forms  of  eczema.  Eichhoff  holds  many 
cases  of  eczema  to  be  of  pp,rasitic  origin. 

In  some  of  the  forms  of  eczema,  especially  in  its  chronic  varieties, 
the  vesicles  supposed  to  characterize  the  disorder  can  often  not  be 
found.  This  and  other  reasons  have  caused  several  dermatologists, 
especially  Hebra  and  Anderson,  to  deny  that  eczema  need  be  vesicular 
at  all.  Infiltration  of  the  skin,  exudation  on  its  surface,  the  formation 
of  crusts,  and  itching,  are  held  to  be  its  distinctive  signs  while  the 


878  MEDICAL  DIAGNOSIS. 

eruption  is  at  its  height ;  but  the  eruption  may  consist  of  clusters  of 
papules,  vesicles,  or  pustules,  or  there  may  not  be  a  vestige  of  any  of 
these,  the  skin  being  thickened,  red  and  smooth,  and  secreting  a  sticky 
fluid,  or  covered  with  green  or  gummy  crusts,  or  fissured  with  deep 
cracks ;  yet  there  are  no  ulcerations.  Not  infrequently  the  disorder 
begins  as  an  erythema.  A  scaly  form  of  eczema,  eczema  squamosum, 
is  apt  to  be  confined  to  the  hands  and  feet.  In  all  the  forms  of  ec- 
zema there  is  severe  itching.  This  itching  is  especially  violent  in  the 
form  with  the  deep-red  and  weeping  surface,  the  eczema  rubrum,  often 
seen  in  gouty  or  in  dyspeptic  subjects,  and  having  a  predilection  for 
the  flexures  of  the  joints. 

Eczema,  when  it  affects  the  scalp  and  face,  must  not  be  confounded 
with  the  morbid  secretion  from  the  sebaceous  follicles  that  gives  rise  to 
soft  crusts.  Sehorrhoea  by  preference  attacks  the  parts  mentioned  ;  but 
its  crusts,  as  Hardy  has  shown,  are  unlike  those  of  eczema  in  the 
readiness  with  which  they  are  detached  and  are  susceptible  of  being 
moulded  between  the  fingers.  The  surface  beneath  the  crusts,  too,  is 
dissimilar.  It  has  an  oily,  glistening  look ;  there  is  no  discharge. 
Unna^  has  distinguished  a  seborrhceic  form  of  eczema,  which,  begin- 
ning usually  on  the  scalp,  spreads  to  other  portions  of  the  cutaneous 
surface ;  but  he  attributes  the  source  of  the  fatty  scales  and  crusts  to 
disorder  of  the  sudoriparous,  rather  than  to  the  sebaceous  glands. 
Patches  of  seborrhceic  eczema  are  also  found  in  the  sternal  region, 
which,  after  the  scalp,  is  the  locality  most  frequently  affected,  the 
patches  spreading  by  small  papules  at  the  border,  leaving  the  centre ' 
less  scaly  and  even  smooth,  while  the  margin  is  a  red,  scale-covered 
wall. 

Eczema  may  be  confounded  with  pityriasis  rubra.  But  this  rare 
disease  speedily  involves  the  whole  surface  of  the  body,  is  very 
chronic,  is  not  accompanied  by  discharge,  and  there  are  large,  thin 
epidermic  scales. 

Herpes. — This  is  a  vesicular  affection,  differing  from  the  vesicular 
form  of  eczema  by  the  larger  size  of  the  vesicles.  These  are  of  a 
globular  form,  and  are  symmetrically  arranged  in  clusters  upon  an 
inflamed  patch  of  skin.  Each  vesicle  is  distinct,  and  remains  so 
throughout  its  course.  It  lasts  about  eight  to  twelve  days,  and  often 
terminates  by  the  formation  of  a  thin  incrustation.  The  eruption  is 
attended  with  burning,  and  in  the  acute  variety  with  some  fever. 

Herpes  has  seldom  a  longer  duration  than  three  weeks  ;  though  it 
may  be  a  chronic  disease.     It  happens  usually  in  persons  of  delicate 

'  Journal  of  Cutaneous  and  Genito-Urinary  Diseases,  1887. 


DISEASES  OF  THE   SKIN.  879 

skin  :  is  generally  limited,  having  its  seat  on  the  lips,  eyelids,  prepuce, 
or  pudenda ;  and  is  very  often  associated  with  an  internal  disorder, 
especially  with  irritation  of  some  portion  of  the  gastro-pulmonary 
mucous  membrane.  Herpes  lahialis  mostly  appears  at  the  decline  or 
termination  of  fevers;  sometimes  at  tlie  height  of  acute  maladies,  as 
in  pneumonia.  The  most  distressing  form  of  herpes  is  that  usually 
extending  around  one-half  of  the  trunk, — herpes  zoste7\  an  acute  dis- 
order, which  may  show  itself  over  the  course  of  any  of  the  super- 
ficial nerves,  and  is  attended-  by  nerve-pain.  Indeed,  herpetic  or 
bullous  eruptions  often  happen  over  the  course  of  the  nerves,  and  any 
nerve-lesion  the  result  of  disease  or  of  an  injury  will  produce  them. 
In  herpes  zoster  around  the  chest,  the  severe  pain  preceding  the 
eruption  is  often  mistaken  for  pleurisy,  but  palpation  will  reveal 
local  spots  of  tenderness  along  the  course  of  the  affected  intercostal 
nerve. 

Herpes  and  eczema  may  both  be  confounded  with  scabies,  which, 
like  them,  occasions  a  vesicular  eruption  that  is  apt  to  be  found  on 
the  inner  surface  of  the  limbs  and  flexures  of  the  joints  and  on  the 
•dorsum  of  the  hands  between  the  fingers.  The  distinction  consists  in 
the  locality  affected  ;  in  the  more  severe  itching,  especially  at  night ;  in 
the  small  conical  vesicles,  torn,  as  they  usually  are,  by  scratching  ;  and 
in  the  presence  of  the  acarus,  which  may  be  removed  from  its  burrow 
with  the  point  of  a  needle  or  of  any  sharp  instrument. 

Bullous  Diseases. — Bullae  differ  from  vesicles  only  in  their  size. 
The  typical  bullous  disease  is  pempthigus.  This  affection,  more  com- 
mon in  children  than  in  adults,  appears  in  very  large  vesicles  or 
bullcB  surrounded  by  a  slight  zone  of  erythematous  redness.  The 
Webs  occur  in  crops,  and  look  like  small  blisters  filled  with  serum. 
They  are  not  met  with  on  the  scalp.  Where  there  are  few  bulla?,  we 
generally  find  them  on  the  ankle  or  on  the  hand.  The  disorder  may 
be  acute  or  chronic.  It  is  ordinarily  chronic,  and  happens  in  persons 
of  enfeebled  constitution.  Relapses  are  frequent,  and  a  fatal  result  is 
common.  Pemphigus  may  be  produced  by  the  administration  of 
iodide  of  potassium,^  or  by  syphilis.  Syphilitic  pemphigus  is  mainly 
met  with  on  the  soles  of  the  feet  and  the  palms  of  the  hands  of 
newly  born  syphilitic  cliildren.  There  is  a  form  of  extensive  pemphi- 
gus witli  flaky  incrustations  like  eczema, — pemphigus  foliacevs ;  but 
we  can  still  find  bulhp,  and  there  is  great  attending  prostration. 
Neurotic  vesicular  erythema  occurs  after  injury  to  a  nerve,  and  some- 
times causes  blebs  which  may  be  mistaken  for  hripe.s  or  pK'mjihigus,  as 


'  Buiiislfiul,  Amer.  Journ.  Med.  Sci.,  July,  1872. 


880  MEDICAL   DIAGNOSIS. 

in  a  case  reported  by  Shields/  in  which  recurrent  attacks  of  vesicular, 
or  bullous,  erythema  were  observed  in  the  forearm,  following  the 
crush  of  a  finger.  The  symptoms  were  entirely  obviated  by  amputa- 
tion of  the  stump  of  the  finger,  after  the  affection  had  existed  for  a 
period  of  three  years. 

Hydroa. — This  is  a  disease  like  herpes,  only  occurring  in  a  more 
diffused  manner  and  presenting  larger  vesicles,  arranged  for  the  most 
part  in  the  form  of  crescentic  rings.  It  is  a  chronic  condition,  lasting 
usually  from  five  to  eight  months,  and  there  are  in  this  period  many 
acute  or  subacute  outbreaks,  in  which  the  large  vesicles  form  and 
then  dry  away.  These  attacks  are  non-febrile,  and  are  attended  with 
marked  itching.  The  disorder  happens  chiefly  in  persons  of  depressed 
nervous  system  or  gouty  taint.  It  has  been  confounded  with  the 
eruption  of  bullae  from  iodide  of  potassium ;  but  these  are  much 
larger,  are  more  persistent,  and  leave  a  marked  scar.  Van  Harlingen 
considers  cases  of  hydroa  to  be  examples  either  of  erythema  iris  or 
of  dermatitis  herpetiformis. 

Pustular  Diseases. — These  are  marked  by  circumscribed  eleva- 
tions of  the  cuticle  which  contain  pus.  Acne,  impetigo,  and  ecthyma 
belong  to  this  group.  Rupia,  too,  although  often  classed  among  the 
bullous  disorders,  appertains  more  strictly  to  the  pustular  or  to  the 
syphilides. 

Acne. — This  is  an  eruption  of  hard,  isolated,  red  elevations,  due  to 
chronic  inflammation  of  the  sebaceous  follicles  and  the  areolar  tissue 
around  them ;  plugs  of  sebum  are  retained  in  the  ducts.  At  the 
apices  of  many  of  these  elevations  pus  forms,  which  is  discharged, 
leaving  a  hardened  base,  that  only  gradually  disappears.  Acne  is  gen- 
erally seen  on  the  face  and  shoulders.  Men  of  sedentary  occupations 
and  drunkards  are  very  liable  to  it.  In  women  it  is  frequently  asso- 
ciated with  uterine  disturbances ;  in  men,  with  some  digestive  or 
genito-urinary  disorder.  An  acne  eruption  also  follows  the  use  of  the 
bromides  and  the  iodides  internally,  and  the  local  use  of  tar.  In  acne 
rosacea,  lymph  is  generally  effused  into  the  papillary  layer  of  the  skin, 
and  some  acne  pustules  are  seen,  surrounded  by  the  reddened,  altered 
skin.  It  is  a  disease  of  years'  duration,  but  no  ulcerations  happen, 
although  scarring  is  a  not  infrequent  result  from  the  small  abscesses. 
Unna  has  reported  the  discovery  of  a  special  bacillus  in  acne,  but 
Lomry  ^  is  of  the  opinion  that  it  is  a  mild  variety  of  bacterium  coli, 
and  that  the  staphylococcus  pyogenes  albus  is  also  present   in   the 

1  The  Cincinnati  Lancet-Clinic,  May  25,  1895. 
'^  Dermat.  Zeitung,  Bd.  iii.  H.  4. 


DISEASES  OF  THE   SKIN.  881 

pustules  of  acne.  In  ordinary  comedo,  unaccompanied  by  inflamma- 
tion, microbes  are  present  in  abundance,  the  staphylococcus  albus 
being  always  represented,  though  less  numerous  than  in  pustular  acne. 

Impetigo. — This  is  a  malady  often  happening  in  persons  of  good 
general  health.  It  presents  small  pustules  occurring  in  successive 
crops,  arranged  in  clusters.  The  pustules  are  isolated,  are  little  raised 
above  the  surface,  break,  and  a  thick  yellowish  or  greenish  crust  is 
developed  ;  no  scar  follows.  When  the  disorder  attacks  the  scalp  and 
face,  especially  in  infants  and  children,  it  gives  rise  to  extensive  in- 
crustations, and  constitutes,  particularly  if  conjoined  with  eczema,  the 
affection  designated  as  "  porrigo  larvalis.'"  There  is  a  contagious  form, 
described  by  Tilbury  Fox,  which  occurs  acutely,  is  epidemic,  preceded 
by  fever,  and  unattended  with  pain  or  itching.  Another  form  of 
impetigo,  first  mentioned  by  Hebra,  consists  in  a  multiform  eruption 
of  vesicles,  vesico-pustules,  and  pustules. 

Impetigo  contagiosa  is  characterized  by  vesico-pustules  or  blebs 
drying  into  flat,  straw-colored  crusts.  It  is  contagious,  and  is  espe- 
cially encountered  in  children.  The  lesions  occur  chiefly  on  the  face 
and  hands  ;  the  contents,  at  first  serous,  become  sero-purulent  in  the 
process  of  drying. 

Dermatitis  herpetiformis  or  .Duhring''s  disease,  differs  in  being  not 
contagious,  and  in  its  happening  in  older  persons  who  are  frequently 
of  an  hysterical  type.  Leredde  and  Parin,  at  the  Hopital  St. -Louis, 
found  in  the  skin,  at  the  site  of  the  lesions,  numbers  of  eosinophile 
granules  and  cells.  There  is  a  close  connection  between  this  disease 
and  the  herpes  of  pregnancy,  in  which  the  same  cellular  elements 
have  been  found.^  There  is  deficiency  of  urea  in  the  urine  of  Duhr- 
ing's  impetigo,  and  Bar  found  that  the  toxicity  of  the  urine  was  in- 
creased at  the  time  that  the  eruption  occurred.  The  disease  is  re- 
garded by  many  as  a  cutaneous  neurosis ;  but  Leredde  suggests  that 
the  exciting  cause  may  be  deficient  elimination  by  the  kidneys,  and 
nephritis  has  been  found  by  Gaston  ^  in  two  autopsies. 

Danlos  '^  has  reported  the  case  of  a  syphilitic  patient,  who,  after  the 
administration  of  potassium  iodide  for  a  short  time,  suffered  with  a 
typical  dermatitis  herpetiformis  affecting  the  hands,  face,  ears,  feet, 
trunk,  and  arms.  A  condition,  therefore,  indistinguishable  from 
Duhring's  disease  may  occur  among  the  rarer  symptoms  of  iodism. 

'  Aii;itoiui(>  pathologique  de  la  Denuiitose  de  DuliriiiLi'  :  Aiiiinlfs  dc  Dcniialolo- 
gie  et  de  Syi)liiligraphie,  No.  4,  April,  1895. 

^  Annales  de  Derin.  v\.  de  Syph.,  Paris,  April,  1895. 
»  Societe  Medicale  des  Hnpitaux  de  Paris,  1899. 

;")■) 


882  MEDICAL  DIAGNOSIS. 

Ecthyma. — This  differs  from  impetigo  by  the  larger  size  and  greater 
prominence  of  the  pustules  and  their  inflamed  base.  When  the  crust 
that  forms  on  each  pustule  falls,  a  highly-congested  surface  or  a  super- 
ficial ulceration  is  seen,  which  leaves  a  cicatrix.  The  disorder  is 
painful,  generally  chronic,  and  connected  with  a  cachectic  state  of  the 
system  ;  irritation  of  the  skin  may  excite  it.  It  bears  a  certain  resem- 
blance to  sycosis  ;  but  the  limitation  to  the  hairy  portions  of  the  face, 
the  yellow  color  of  the  pustules,  their  conical  form  and  smaller  size, 
and  the  brown  crusts  they  occasion,  distinguish  this  malady. 

Eupia. — This  affection  produces  at  first  bullse,  but  soon  large  pus- 
tules, which  desiccate  into  thick,  brownish  crusts,  often  of  conical 
shape  or  resembling  the  shell  of  an  oyster ;  when  thrown  off  ulcer- 
ations of  various  depths  are  exposed  that  are  slow  to  heal,  and  on 
which  fresh  crusts  arise.  The  disease  runs  a  chronic  course.  It 
occurs  especially  on  the  lower  extremities,  and  is  due  to  syphilis.  It 
is  very  like  ecthyma,  and  can  be  distinguished  only  by  the  history  of 
the  case,  the  evidences  of  syphilitic  taint,  the  persistent  ulcerations, 
and  the  prominent,  peculiarly  shaped  crusts. 

Squamous  Diseases. — The  predominant  characteristic  of  these 
is  the  formation  of  small,  whitish  patches  of  unhealthy  cuticle  cover- 
ing red  papular  elevations  on  a  deep-red,  dry,  somewhat  thickened 
surface  ;  the  scales  are  generally  very  freely  cast  oft\  Psoriasis  is  the 
main  disorder  belonging  to  the  group.  Pityriasis  is  included  by  many, 
while  others  regard  it  as  merely  a  variety  of  chronic  erythema,  or  of 
eczema.  It  differs  from  lepra  and  psoriasis  by  the  production  of 
minute  scales,  which  are  constantly  thrown  off  and  reformed,  and 
which  are  seated  on  a  reddened  integument ;  hence  its  chief  variety 
is  designated  pityriasis  rubra.  It  begins  at  a  special  point,  and,  unlike 
psoriasis,  spreads  over  the  whole  body.  The  skin  is  very  red,  and  not 
thickened,  except  in  instances  of  long  standing ;  there  is  no  discharge, 
as  in  eczema,  nor  itching  or  burning ;  the  scales  are  loosely  adherent 
to  the  surface,  and  at  times  come  off  in  large  flakes.  The  disease  is 
most  apparent  on  the  body  and  the  limbs ;  in  chronic  cases  the  gen- 
eral health  deteriorates,  and  a  fatal  result  is  the  rule.  Pityriasis  rubra 
is  to  be  distinguished  from  exfoliative  dermatitis,  which  is  an  acute 
affection  and  more  amenable  to  treatment.  In  this  disease  the  scales 
are  thicker,  larger,  and  more  abundant  than  in  pityriasis  rubra ;  there 
may  be  some  spots  of  moist  eczema,  the  lesions  being  papular  at  first 
and  then  vesicular,  ending  in  profuse  exfoliation,  large  casts  coming 
away  from  the  fingers  and  toes.  Alopecia  and  shedding  of  the  nails 
are  common. 

Pityriasis  rosea.,  or  pityriasis  maculata  et  carcinata  of  Duhring,  is 


DISEASES  OF  THE  SKIN.  883 

recognized  by  the  presence  of  maculae,  or  very  slightly  elevated 
patches,  varying  from  a  pin-point  to  a  half-dollar  in  size,  the  color 
being  rosy,  or  pink,  with  a  yellowish  tint.  The  surface  of  the  lesions 
is  dry  and  slightly  scaly ;  the  appearance  is  circinate.  The  eruption 
usually  appears  on  the  trunk,  is  moderately  acute,  and  may  last  two 
or  three  months  or  longer.  It  is  not  contagious,  and  apparently  is  not 
parasitic  in  origin,  though  this  is  a  matter  of  much  doubt.  The  gen- 
eral health  is  not  impaired,  and  the  patches  give  no  annoyance  except 
by  the  itching,  which  is  not  excessive,  and  by  their  appearance,  which 
may  lead  to  their  being  taken  for  lesions  of  syphihs,  or  for  ringworm, 
lichen  ruber,  psoriasis,  or  one  of  the  eruptive  fevers,  as  in  cases 
reported  by  Duhring  and  Stelwagon. 

Psoriasis. — Here  we  find  patches  of  a  red  hue  raised  above  the 
surrounding  integument  and  covered  by  scales  of  dried  epidermis. 
The  patches  are  infiltrated  and  thickened,  and  they  often  have  a  cir- 
cular shape,  with  large  pearly  white  scales.  More  generally  the  scales 
which  completely  cover  the  morbid  portion  of  skin  are  small,  though 
thick ;  the  patches  are  large  or  consist  of  small  ones  which  have 
coalesced,  are  not  of  an  annular  form,  or  completely  separated  by 
healthy  skin  ;  they  are  symmetrical.  Psoriasis  generally  first  appears 
on  the  extensor  surfaces  of  the  elbow-  and  knee-joints,  and  finally  on 
the  face.  As  Beverley  Robinson  has  proved,  the  morbid  change 
begins  in  the  cells  of  the  epidermis.  There  is  no  watery  discharge, 
and  scarcely  any  itching. 

Psoriasis  is  often  hereditary  ;  in  old  persons  it  is  frequently  of 
gouty  origin.  It  is  a  chronic  affection,  and  extremely  obstinate.  It 
is  liable  to  be  mistaken  for  lichen,  especially  the  isolated  circular  form 
of  it,  the  so-called  lepra.  It  is,  however,  distinguished  by  the  distinct, 
dry,  and  silvery  scales,  and  by  the  smooth,  red,  perhaps  bleeding  skin 
which  is  at  once  perceived  when  the  scales  are  detached.  Psoriasis 
has  a  predilection  for  the  vicinity  of  the  joints,  especially  the  elbow- 
and  knee-joints.  Sometimes  it  appears  exclusively  on  the  palm  of  the 
hand ;  and  in  this  form  especially  we  are  apt  to  find  deep  cracks. 
Palmar  psoriasis  is  rare  ;  but  a  condition  resembling  it  in  the  produc- 
tion of  scales  and  fissures  occurs  often  in  constitutional  syphilis,  the 
so-caWed  si/philitic  2^soriaf;is.  Psoriasis  differs  from  eczema  squamosum 
by  the  preceding  vesicles,  severe  itching,  and  the  want  of  uniformity 
of  lesion  of  the  latter.  In  scaly  syphilitic  eruption  the  scales  are 
comparatively  few  and  fine  ;  when  they  are  removed,  the  dense  skin 
underneath  does  not  bleed ;  and  the  eruption  is  not  likely  to  be  met 
with  on  the  elbows  and  the  knees. 

Icthyosis. — Fish-skin    is    also  a  squamous    disease  ;  but   it  differs 


884  MEDICAL  DIAGNOSIS. 

from  the  others  of  this  class  in  involving  often  the  whole  integument, 
and  in  the  absence  of  reddening  or  any  signs  of  inflammation  of  the 
harsh,  dry  surface ;  it  is,  indeed,  an  hypertrophy  of  the  cuticle.  The 
skin  is  dry,  dirty,  and  rough,  and  covered  with  thickened  and  exfoli- 
ating cuticle  and  with  sebum  ;  there  may  be  also  fissures  and  cracks. 
Ichthyosis  is  almost  always  of  congenital  origin  and  begins  in  child- 
hood :  it  affects  the  whole  body,  though  the  face  but  slightly. 

Among  the  inflammatory  diseases  of  the  skin,  those  resulting  from 
medicines  may  be  here  mentioned.  This  dermatitis  medicamentosa  is 
brought  about  by  a  variety  of  drugs,  and  diff'ers  according  to  the 
special  drug.  Among  the  principal  ones  producing  morbid  appear- 
ances of  the  skin  are  arsenic,  quinine,  belladonna,  opium,  chloral, 
salicylic  acid,  antipyrin,  copaiba,  the  bromides,  and  the  iodides.  The 
acneiform  eruption  due  to  the  bromides,  mth  the  dusky-red  color  of 
parts  of  the  skin,  or  the  ulcers  they  may  occasion ;  the  papular  or 
bullous  eruption  caused  by  the  iodides,  especially  by  iodide  of  potas- 
sium, and  the  scarlet  rash  of  befladonna, — are  well  known. 

Maculae. — These  include  blood-spots,  as  in  purpura,  or  spots  in 
consequence  of  parasitic  formations,  as  in  tinea  versicolor.  But  their 
chief  cause  is  increased  pigmentation. 

First,  lentigo  may  be  mentioned.  This  consists  of  the  little  yellow 
or  yellowish-brown  spots  which  are  so  often  observed  on  the  face  and 
on  the  arms  in  children  under  eight  years  of  age,  and  which,  if  they 
have  persisted,  disappear  in  middle  life.  Similar  spots  are  ephelides, 
or  freckles  ;  these,  though  aggravated  by  exposure  to  the  sun,  may 
exist  all  the  year  round.  Melasma  is  a  very  dark  pigmentation,  which, 
although  it  has  been  met  with  in  an  epidemic  form,  is  commonly  seen 
in  connection  with  Addison's  disease. 

Chloasma  consists  of  a  brownish  or  yellowish-brown  pigmentation, 
giving  rise  to  the  so-called  liver  spots.  They  are  smooth  and  well- 
defined  maculse  without  scales,  and  may  result  from  any  local  irrita- 
tion, or  from  exposure  to  the  sun  or  heat.  They  may  also  happen  in 
cases  of  faulty  digestion  with  torpor  of  the  liver,  in  uterine  disorders, 
and  in  the  pregnant  state.  Tinea  versicolor  is  constantly  confounded 
with  these  so-called  liver  spots.  But  it  is  almost  entirely  a  disease  of 
the  trunk,  is  much  more  itchy,  is  slightly  raised,  and  in  the  scales  we 
scrape  off  is  found  the  characteristic  fungus. 

Ne"W  Growths. — These  are  hard,  indolent,  and  often  permanent 
tumors  of  the  skin,  which  in  their  main  forms  consist  of  granulation 
tissue.  Lupus,  fibroma  molluscum,  and  elephantiasis  of  the  Greeks 
mainly  illustrate  this  group. 

Lupus. — In  lupus  the  new  growth  mostly  takes  place  in  the  form 


DISEASES  OF  THE  SKIN.  885 

of  isolated  tubercles.  Ttiese  may  or  may  not  ulcerate.  They  are  of 
a  dull-red  color,  elevated  above  the  surface,  with  a  well-defined  out- 
line, spread  outward  into  normal  textures,  and,  if  they  ulcerate,  de- 
stroy the  tissues  in  which  they  are  situated.  The  ulcers  also  spread, 
and  occasion  much  devastation.  When  they  heal,  they  leave  a 
strongly  marked  whitish  cicatrix  and  unhealthy-looking  skin.  The 
disorder  occurs  in  syphilitic  or  in  scrofulous  persons, — generally  in 
the  latter, — appears  often  in  childhood,  is  attended  with  some  pain 
and  itching,  and  pursues  a  very  slow  course.  The  nose  and  cheek 
are  the  favorite  sites.  There  is  a  form  of  lupus  occurring  in  strumous 
subjects,  and  characterized  by  warty  formations.  This  lupus  verru- 
cosus is  without  pain  or  itching,  but  cicatrices  form,  even  though  there 
have  been  no  previous  ulceration.^  In  lupus  erythematodes  the  disease 
is  superficial,  and  the  sebaceous  glands  particularly  are  distended. 
The  surface  is  somewhat  raised,  the  centre  of  the  diseased  patch  is 
pale  and  sinks  in.  The  nodules  form  late,  if  at  all,  and  there  is  no 
ulceration.  The  most  common  site  of  the  disease  is  under  the  eye. 
It  does  not  generally  appear  until  after  puberty,  and  is  preceded  by 
erythema  of  the  affected  parts.  The  diagnosis  of  hqnis  vulgaris  de- 
pends principally  upon  the  small  nodules  of  granulation  tissue  deeply 
embedded  in  the  corium  of  the  skin,  that  have  a  tendency  to  undergo 
ulceration,  and  leave,  upon  healing,  a  peculiar  cicatrix  of  uneven  thick- 
ness. Tubercle-bacilli  and  giant-cells  are  found  in  these  lesions, 
which  are,  mdeed,  due  to  the  tubercle-bacilli. 

Lepjra. — Leprosy  is  a  chronic  constitutional  disorder,  and  the 
symptoms  of  general  depression  may  precede  the  characteristic  local 
features.  The  true  leprosy,  the  elephantiasis  of  the  Greeks,  is  dis- 
tinguished by  tubercles,  from  the  size  of  a  pea  to  that  of  a  walnut,  of 
reddish  or  whitish  or  bronze-like  hue,  which  slowly  ulcerate,  and 
which  are  preceded  by  erythematous  patches  ;  ulceration  is  apt  to 
take  place  about  the  fmgers  and  toes.  Like  lupus,  the  tubercles  have 
the  structure  of  granulation  tissue.  Often,  too,  there  are  symptoms 
of  defective  innervation,  especially  deficient  sensation  of  the  surface, 
anaesthesia  of  the  fingers  being  an  early  symptom.  The  nerve-trunks 
are  invaded,  cutaneous  eruptions  in  their  course  result,  and  the  blood 
is  seriously  affected.  Muscular  weakness  and  wasting  may  be  also 
present.  The  face  is  most  frequently  the  seat  of  the  malady,  and  be- 
comes very  much  thickened  and  disfigured  ;  similar  changes  may  also 
be  seen  in  the  limbs.  Pemphigus-like  blebs  are  among  the  earliest 
signs.     When    marked    nodules    form,  the  skin   is    discolored,  often 

^  McCall  Anderson.  Jourmil  of  Cutaneous  Medicine.  atjI.  i. 


886  MEDICAI.   DIAGNOSIS. 

copper-colored,  and  the  face  is  distorted  and  has  a  fierce  expression. 
Sometimes  anaesthesia  is  the  main  symptom  ;  the  uneven  thickening- 
may  occur,  without  tubercles,  in  circular  patches  like  psoriasis,  and 
be  markedly  anaesthetic.  The  disease  is  often  hereditary.  Syringo- 
myelia, presenting  trophic  changes,  closely  resembles  angesthetic  lep- 
rosy ;  and  Zambaco  ^  has  shown  that  cases  supposed  to  be  typical 
illustrations  of  Morvan's  disease  and  reported  as  such  were  in  reality 
cases  of  leprosy.  The  presence  of  the  lepra  bacillus  in  the  lesions  or 
in  the  blood  would  decide  the  diagnosis  in  any  doubtful  case. 

Two  forms  of  the  disease  are  recognized, — the  tubercular  and  the 
anaesthetic ;  but  there  is  no  absolute  distinction  between  them.  The 
disease  is  found  in  the  east,  in  Africa,  in  Brazil,  in  Norway,  and  in 
the  Hawaiian  Islands  ;  a  few  cases  exist  m  the  United  States. 

Hypertrophies. — There  are  many  forms  of  these,  according  to 
whether  the  connective  tissue,  the  epidermis,  the  arteries  and  veins, 
or  the  lymphatic  vessels  are  affected.  I  shall  notice  particularly  two  ; 
and  first,  elephantiasis  Arabum. 

Elephantiasis  of  the  Arabs. — This,  the  Barbadoes  leg,  is  an  enor- 
mous increase  in  size  of  the  limb,  usually  dependent  upon  an  indu- 
rated swelling  of  the  subcutaneous  tissues,  with  some  alteration  of 
the  skin  proper,  and  lymphangitis.  The  tumefaction  may  be  in  swell- 
mgs  separated  by  deep  furrows,  giving  somewhat  of  a  tuberculated 
look  to  the  part,  or  it  may  be  uniform ;  it  chiefly  attacks  males,  and 
occasions  great  deformities.  It  is  a  disease  of  the  tropics.  Cases, 
especially  of  elephantiasis  of  the  scrotum,  have  been  frequently  traced " 
to  filariEe,  or  to  repeated  attacks  of  erysipelas. 

There  is  a  form  of  enlargement  of  the  leg  to  which  we  may  here 
briefly  refer, — one  in  which  the  overgrowth  of  the  affected  limb  is 
associated  with  disease  in  the  lymphatic  system.  Vesicles  form,  which 
are  connected  by  ridge-like  elevations,  and  which  from  time  to  time 
discharge  a  chylous  fluid.^  The  subcutaneous  lymphatics  near  the 
groin  are  usually  found  to  be  distended. 

Scleroderma. — Scleroderma,  or  sclerema,  is  an  induration  of  the 
skin  and  areolar  texture,  which  may  be  partial  or  general,  affecting 
nearly  the  whole  body.  The  skin  is  dense  and  hard,  and  in  the  true 
skin  and  the  subcutaneous  tissue  the  fibrous  elements  are  much  in- 
creased. The  true  skin  shrinks  and  binds  down  and  is  bound  to  the 
parts  beneath.  If  the  malady  seize  upon  the  fingers,  it  renders  them 
rigid.     The  disease  is  generally  symmetrical,  and  much  more  common 

^  See  Gould's  Year-Book  of  Medicine  and  Surgery,  1897,  p.  860. 
MV.  H.  Day,  Transact.  Clin.  Soc.  Lond.,  vol.  ii.,  1869. 


DISEASES  OF  THE  SKIN.  887 

in  women  than  in  men ;  it  may  appear  after  unusual  exposure  to  cold 
and  resulting  frost-bite/  It  frequently  coexists  with  feeble  health ; 
and  in  time  the  internal  organs  become  affected,  or  these  are  from 
the  first  implicated."  Yet  the  general  health  may  remam  good.  In 
generalized  scleroderma  the  plaques  may  appear  on  any  portion  and 
extend  over  almost  the  whole  surface  of  the  body,  as  in  the  case 
described  by  Leredde  and  Thomas.^ 

I  had  some  years  since  a  marked  case  of  this  strange  affection 
under  my  charge  at  the  Pennsylvania  Hospital,  in  a  woman,  forty-two 
years  of  age,  who,  admitted  with  oedema  of  the  feet,  Avas  at  the  same 
time  noticed  to  have  a  swelling  of  both  wrists  and  forearms  as  well  as 
of  the  cheeks.  The  swelling  was  firm  and  resistant,  and  did  not  pit 
on  pressure.  The  skin  covering  it  was  very  smooth,  and  of  redder 
hue  than  at  other  portions  of  the  body  ;  there  was  well-preserved  sen- 
sibility. The  cedema  disappeared  from  the  feet,  but  the  signs  of  the 
indurated  cellular  tissue  did  not  leave  the  affected  parts.  On  the 
contrary,  the  condition  of  these  parts  became  worse,  though  the  gen- 
eral health  was  excellent,  all  the  internal  viscera  being  in  a  normal 
state.  Gradually  the  hands,  particularly  the  fingers,  were  found  to 
be  more  and  more  resisting  and  immovable,  and  she  could  scarcely 
bend  them  ;  occasionally  they  were  the  seat  of  pain.  The  skin  lost 
all  suppleness,  and  could  not  be  raised  up.  At  no  time  while  under 
observation  was  albumin  present  in  the  urine.  She  left  the  hospital 
unimproved  by  the  sulphur  baths,  the  bichloride  of  mercury,  and  the 
various  other  alteratives  she  took ;  and  I  afterwards  learned  that  she 
died  of  an  acute  pleurisy  succeeding  an  attack  of  acute  meningitis. 
Prior  to  her  death,  so  great  was  the  pressure  exerted  by  the  dense 
and  contracting  areolar  tissue  that  dry  gangrene  of  a  finger  ensued, 
as  well  as  of  a  toe,  the  disease  having  been  also  noticed  in  the  lower 
extremities.  She  died  about  one  year  from  the  beginning  of  the  dis- 
ease. Examined  after  death,  the  skin  of  the  affected  parts  was  found 
firmly  united  to  the  muscles  by  the  dense  areolar  textures. 

Scleroderma  is  very  similar  in  many  of  its  features  to  myxadema. 
But  the  marked  anaemia  of  this,  the  decided  nervous  symptoms,  and 
the  fact  that  we  do  not  find  the  stiff,  hard  skin  compressing  the  parts 
beneath  causing  in  time  marked  -atrophies,  distinguish  the  two  mala- 
dies. The  successful  treatment  of  myxoedenia  by  thyroid  extract  sug- 
gests a  means  of  diagnosis  between  the  two  affections.     Goldzieher* 

'  Goldzieher,  Beitrage  der  Berlin.  Dermatolog.  Gescllsch.,  March,  1893. 

■^  Harley,  Med.-Chir.  Transact.,  1877. 

•'  Archives  de  Med.  Exp.  et  d'Anat.  Path.,  Sept.  1898. 

*  BeitriiLfe  der  Berlin.  Dermatolog.  Gesellsch.,  March  12,  ^.'^;•.".. 


MEDICAL  DIAGNOSIS. 

considers  scleroderma  a  progressive  clironic  dermatitis  accompanied 
by  permanent  oedema.  Repeated  attacks  of  erysipelas  thicken  the 
skin,  but  we  do  not  find  atrophies  from  compression. 

Scleroderma  is  closely  related  to  morphoea.  This  occurs  over  the 
course  of  nerve-tracts,  the  thickening  being  in  circumscribed  patches 
and  lacking  the  peculiar  hardness  of  sclerema ;  then  changes  in  the 
structure  of  the  skin,  hypersemic  appearances  at  first,  pigmentation 
and  cicatrization  afterwards,  occur  in  morphoea,  with  pain  and  tingling 
in  the  affected  parts.  The  color  of  the  patch  of  morphoea  is  charac- 
teristic. The  central  part  is  usually  of  a  yellowish-white  or  ivory 
color,  which  is  surounded  by  a  zone  of  lilac,  due  to  enlarged  capil- 
laries. By  some,  morphoea  is  regarded  as  a  local  expression  and  ah 
early  stage  of  scleroderma,  each  being  a  form  of  trophoneurosis. 
There  is  a  possibility  of  mistaking  the  local  asphyxias  occurring  in 
symmetrical  patches  and  characteristic  of  Raynaud's  disease  for  scle- 
roderma, but  the  course  of  this  disease  is  short,  lasting  only  ten  days, 
and  ending  either  in  gangrene  or  complete  restoration  of  function.  It 
should  be  remembered,  however,  that  Raynaud's  disease  is  not  con- 
fined to  the  digits,  but  may  occur  on  the  forearm  or  leg,  and  other 
portions  of  the  body.  The  local  asphyxia  of  the  fingers  met  with  in 
hysterical  patients  is  a  fugacious  phenomenon,  and  is  not  caused  by 
any  organic  change  in  the  nerve-supply.  It  usually  takes  place  at 
night  and  passes  away  in  the  morning. 

Parasitic  Diseases. — These  may  be  caused  by  the  presence 
either  of  parasitic  animals  or  of  parasitic  plants.  To  affections  of 
the  former  origin,  or  the  epizoa,  belongs  especially  scabies ;  though 
the  various  forms  of  lice  producing  a  pruriginous  eruption  with  little 
hemorrhagic  marks — phtheiriasis — must  be  mentioned.  Another  ani- 
mal parasite,  the  entozoon'  or  demodex  folliculorum,  inhabits  the  seba- 
ceous and  hair-follicles,  but  does  not  cause  disease. 

The  complaints  associated  with  the  vegetable  parasites,  the  epi- 
phytes,— or,  as  those  on  the  skin  are  called,  the  dermatojihytes, — also 
known  by  the  generic  name  of  tinea,  are  chiefly  favus,  mentagra,  pity- 
riasis versicolor,  and  some  of  the  forms  of  ringworm,  tinea  circinata, 
and  tinea  tonsurans.  Pellagra,  supposed,  too,  to  be  due  to  a  vegetable 
parasitic  growth,  is  not  an  affection  met  with  in  this  country.  Nor 
does  the  presumed  parasitic  fungus  lodge  in  the  skin.  It  is  said  to  be 
found  in  diseased  Indian  corn  or  maize,  which,  when  eaten,  causes  the 
digestive  disorders,  the  general  cachexia,  and  the  erythematous  cuta- 
neous eruption  that  characterize  the  malady.  In  the  chronic  cases 
melancholia,  suicidal  mania,  and  paraplegia  are  met  with.  Belmondo 
found  lesions  of  the  spinal  cord  in  a  number  of  instances. 


DISEASES  OF  THE   SKIN, 


889 


Fig 


Scabies. — Scabies,  or  the  itch,  is  owing  to  the  acaros  scabiei.  Tliis 
burrows  in  the  skin,  particularly  between  the  fingers  and  between  the 
toes,  about  the  wrists,  on"  the  buttocks  and  abdomen,  and  the  upper 
part  of  the  penis.  The  channels  produced  are  curved,  and  may  be 
traced  as  whitish  or  more  generally  black  streaks  several  lines  in 
length,  in  the  situations  just  indicated.  The  disease  is  attended  with 
excessive  itching,  which  is  increased  at  night,  and  with  the  eruption 
of  conicle  vesicles,  or  even  of  a  marked  eczema  and  of  papules  and 
pustules  ;  most  of  the  rash  is  due  to  the  irritation  of  scratching. 

At  the  close  of  our  civil  war  we  had  a  form  of  itch  prevalent  in 
this  country,  spread  far  and  wide,  as  is  presumed,  by  contact  with  the 
troops, — the  so-called  army  itch.  It 
was  a  chronic  and  distressing  affec- 
tion, and  no  age  or  social  state  was 
exempt  from  it.  The  itching  was 
intense  ;  the  eruption  was  like  pru- 
rigo, but  vesicles,  or  even  an  ec- 
zematous  condition  of  the  skin,  or 
pustules,  attended  the  intolerable 
itching ;  and  in  cases  of  long  dura- 
tion the  appearance  of  the  skin 
was  altered,  and  all  trace  of  a  dis- 
tinctive eruption  was  gone.  The 
eruption  was  seen  on  the  arms, 
chest,  abdomen,  and  lower  ex- 
tremities, particularly  on  the  ulnar 
side  of  the  forearm  and  the  inner 
aspect  of  the  thigh.  It  was  sometimes  found  on  the  scalp,  but  sel- 
dom in  the  groins,  in  the  axillae,  on  the  hands,  or  between  the  fingers. 
It  was  benefited  by  sulphur ;  for  almost  all  the  preparations  recom- 
mended for  it  contained  sulphur.  To  what  it  was  due  I  am  unable 
to  say. 

Tinea  Favosa. — Tinea  favosa,  or  favus,  is  a  chronic  disease  that 
gives  rise  to  bright-yellow  umbilicated  crusts,  of  circular  shape,  which 
often  form  yellow  rings  around  the  hair-folhcles.  There  is  no  dis- 
charge. The  disease  rarely  affects  any  other  part  of  the  body  than 
the  scalp,  and  produces  baldness  ;  when  the  nails  are  attacked,  they 
become  brittle  and  yellow.  The  microscope  furnishes  us  with  a  cer- 
tain means  of  diagnosis,  by  exhibiting  the  cryptogamic  plants. 

Tinea  Sycosis. — Tinea  sycosis,  or  barber's  itch,  is  to  be  distin- 
guished from  a  non-parasitic  form.  The  distinctive  marks  of  the 
disease  consist  in  the  development  of  yellowish  pustules,  having   a 


A  female  acarub,  taken  from  a  photograph 
from  nature ;  magnified  220  diameters.  The 
ventral  surface  is  shown. 


890  MEDICAL  DIAGNOSIS. 

bright-red  base,  around  the  roots  of  the  hair  of  the  beard ;  the  hairy- 
portion  of  the  neck  may  be  also  affected.  The  crusts  may  run  to- 
gether, and  more  or  less  inflammatory  thickening  of  the  skin  exist. 
This  is  especially  seen  in  the  parasitic  form  of  the  disease,  in  which,, 
however,  less  suppuration  happens,  and  less  pain  or  itching,  but  in 
which  the  hairs  become  brittle.  The  upper  lip  is  rarely  implicated  in 
tinea  sycosis.  Non-parasitic  sycosis  consists  chiefly  in  an  inflamma- 
tion around  the  follicles,  which  always  starts  in  these  parts.^ 

Tinea  Circinata  and  Tinea  Tonsurans. — The  tricophyton  tonsurans 
is  the  parasite  met  with  in  tinea  ch-cinata,,  the  ringworm  of  the  body, 
and  in  tinea  tonsurans.,  the  ringworm  of  the  scalp.  This  is  common  in 
children,  and  spreads  by  contagion.  It  exists  in  circular  scaly  patches, 
on  which  are  dry  broken  hairs.  In  ringworm  of  the  body  the  patches 
are  also  circular  and  scaly  ;  but  they  are  red  and  very  itchy,  and  much 
paler  in  the  centre  than  at  the  edge.  Examining  the  scurf,  we  find 
the  fungous  growth. 

Tinea  Versioolor. — This  parasitic  affection,  also  known  as  pityriasis 
versicolor,  occasions  those  yellow  or  yellowish-brown  discolorations 
which  may  be  not  infrequently  seen  on  various  parts  of  the  body. 
The  microsporon  furfur  of  Eichstadt  is  the  parasite  present ;  and  it  is 
found  abundantly  in  the  scales  which  can  be  scraped  from  the  raised^ 
itching  patches.  In  pityriasis  affecting  the  scalp  we  may  also  find 
parasitic  growths  of  a  vegetable  nature  ;  they  are  often  tke  cause  of 
baldness,  as  in  ti7iea  decalvans.  Pityriasis  capitis,  or  dandruff,  is  read- 
ily distinguished  from  ordinary  seborrhoea,  in  which  the  oily  element 
predominates  in  the  scales,  that  are  aggregated  in  masses.  This  is  in 
marked  contrast  to  the  fine  pearly  scales  of  pityriasis,  which  are  due 
to  epithelial  exfoHation.     This  condition  often  leads  also  to  baldness. 

The  diagnosis  of  actinomycosis  of  the  skin  depends  upon  the  his- 
tory, and  the  distribution  of  the  tumors  in  necklace-like  series,  either 
in  lines  or  in  circles,  or  in  groups.  The  disease  pursues  a  rapid  course, 
with  fever,  sometimes  septicaemic  in  character.  Majocci^  recognizes 
two  forms,  the  anthracoid  and  the  ulcero-fungous.  In  the  former  the 
lesions  are  flat-topped,  with  a  multitude  of  small  openings  from  which 
thick  yellow  pus  exudes  ;  in  the  latter  ulceration  occurs  early,  with 
large  granulations.  In  neither  form  are  the  lymphatic  glands  in  the 
neighborhood  of  the  lesions  involved.  The  lesions  are  situated  chiefly 
around  the  buccal  cavity.  Microscopical  examination  of  the  yellow 
granules  reveals  the  characteristic  actinomyces. 


Robinson,  New  York  Medical  Journal,  Aul?.  and  Sept.  1877. 
Annales  de  Derm,  et  de  Syph.,  Paris,  1892,  p.  310. 


DISEASES  OF  THE   SKIN.  891 

Altered  Gland- Secretions. — One  of  these,  seborrhoea,  or  in- 
creased secretion  from  the  sebaceous  glands  mixed  with  epidermic 
scales,  has  been  already  mentioned.  It  is  especially  found  on  tlie 
scalp,  nose,  and  genitals,  and  is  often  seen  among  those  who  have 
menstrual  disorders.  It  is  unattended  by  itching ;  the  crusts  are 
readily  removed  by  strong  alkaline  soaps,  and  the  skin  beneatli  is 
healthy,  or  pale  and  glistening,  or  slightly  reddened.  Where  the 
sebum  is  retained  in  the  follicle,  giving  rise  to  little  prominences  dis- 
colored by  dirt,  and  without,  as  happens  in  acne,  inflammation  around 
the  gland  and  its  duct,  the  disorder  is  called  comedo.  The  plug  of 
sebum  can  be  easily  squeezed  out.  The  disorder  is  most  common  on 
the  face  and  shoulders  of  young  persons  of  lymphatic  temperament. 

The  sioeaf-glands  are  often  altered  in  their  activity,  and  excessive 
perspiration  results.  This  may  be  general,  or  confined  to  particular 
localities,  as  to  the  hands  and  feet.  This  local  sweating  is  often  offen- 
sive, and  makes  the  parts  very  tender.  The  disease  formerly  known 
as  lichen  tv'opicus  is  now  regarded  as  due  to  congestion  or  inflammation 
of  the  sweat-glands,  and  is  termed  more  correctly  miliaria  papulosa. 
The  strophulus  or  "  red  gum"  of  infants  is  miliaria  vesiculosa.  At 
times  there  is  sweating  of  blood  from  the  skin.  This  condition,  known 
as  hcemidrosis,  is  due  to  some  alteration  in  innervation,  and  may  be 
preceded  or  accompanied  by  a  localized  erythema  or  eczema ;  or  the 
bleeding  may  come  from  the  follicles  of  the  skin ;  it  is  not  a  secretion 
of  the  sweat-glands,  but  is  a  hemorrhage,  or  an  exudation. 

Molluscum  epitheliale  presents  numerous  globular  or  flatfish  nodules, 
sometimes  seated  on  a  broad  base  or  attached  to  a  pedicle.  They  are 
due  to  a  psorosperm  in  the  deep  layers  of  the  skin  and  in  the  seba- 
ceous glands.  The  lesions  occur  in  groups  on  the  face  or  neck,  or 
on  the  trunk ;  they  have  a  doughy  feel,  vary  in  size  from  that  of  a  pea 
to  that  of  a  pigeon's  q^^.,  show  no  tendency  to  inflame,  and  are  not 
attended  with  increased  sensibility  of  surface.  They  are  of  the  color 
of  the  skin  or  of  brownish  hue.  They  may  last  during  life  without 
affecting  the  general  health.  There  is  a  variety  met  with  especially 
in  children,  which  has  at  the  top  or  the  side  of  each  tubercle  a  small 
orifice,  from  which  a  creamy,  fatty  fluid  can  be  pressed.  This  variety 
is  by  many  regarded  as  contagious.  The  little  tumors  are  distin- 
guished from  so-called  molluscum  fibroma  by  the  central  aperture,  and 
by  the  substance  resembling  sebum  that  can  be  squeezed  out  of  them. 

Although  p^l^Go,  pjolonica  is  of  rare  occurrence  in  this  country,  yet 
among  immigrants  it  is  occasionally  met  with,  and  may  be  recognized 
by  the  mass  of  felted,  matted  hair,  and  the  inflammation  of  the  scalp 
from  which  serous  oozing  occurs.    The  mass  of  hair  affords  refuge  for 


892  MEDICAL   DIAGNOSIS. 

vermin,  and  the  secretions  from  the  scalp  produce  a  pecuhar  odor, 
which  has  led  to  the  supposition  that  the  disease  is  caused  solely  by 
dirt.  Dumesnil  considers  it  a  neurosis  and  the  dirt  only  incidental. 
Under  the  microscope  the  hairs  show  decided  change,  affecting  mainly 
the  medulla.  Jarochevski  has  pronounced  the  disease  a  disturbance 
of  nutrition  of  neurotic  origin. 

Nervous  Affections. — Several  of  these,  such  as  herpes  zoster, 
have  been  already  considered.  The  large  group  of  itching  affections 
in  which  no  obvious  local  affection  exists,  find  here  their  place.  Such 
are,  for  instance,  the  various  forms  of  jjruritus,  either  local  or  general, 
which  are  specially  apt  to  affect  elderly  persons.  Sometimes  the 
itching  is  violent  and  obstinate,  and  we  cannot  even  trace  it  to  re- 
flected irritation,  though  this  is  often  its  cause.  Again,  diabetes,  gout, 
lithaemia,  or  jaundice  may  lie  at  the  root  of  the  pruritus.  Season  in- 
fiuences  it  much,  as  seen  in  the  winter  itching,  the  pruritus  hiemahs, 
described  by  Duhring.  It  happens  particularly  about  the  tliighs  and 
legs,  and  there  may  be  prominence  of  the  hair-follicles.  Among  other 
manifestations  of  nervous  skin  disorders  are  dermatalgia,  hyperses- 
thesia,  and  anaesthesia  ;  then  there  are  a  number  of  cutaneous  diseases 
that  are  being  recognized  as  of  nervous  origin. 

The  affections  of  the  skin  do  not  always  occur  isolated ;  they  may 
be  combined.  Again,  they  are  altered  by  the  existence  of  a  special 
taint,  as  by  the  syphilitic.  Now,  without  attempting  to  describe  syphi- 
litic diseases  of  the  skin,  it  may  be  stated  that  they  differ  by  their 
multiform  lesions,  their  copper-colored  tint,  by  the  stained  aspect  they 
leave,  and  by  the  absence  of  itcliing.  In  syphilitic  erythema  the  erup- 
tion runs  a  chronic  course,  and  is  distinct  on  the  trunk.  It  belongs 
to  early  syphilis.  Syphilitic  lichen  has  better-defined  papules  than 
simple  lichen.  The  ulcerations  in  the  pustular  affections  are  deeper : 
while  in  the  squamous  disorders  the  scabs  are  smaller  and  the  papules 
larger  than  in  the  non-syphilitic  eruptions.  A  furunculoid  eruption  is 
met  with  in  hereditary  syphilis.  Syphilitic  affections  of  the  skin  are 
apt  to  be  mixed,  and  light  is  thrown  on  them  by  this  fact,  as  well  as 
by  the  history  of  the  case,  the  sore  throat,  the  falling  of  the  hair,  and 
the  nerve-  and  bone-pains. 


CHAPTER    XIV. 

POISONS  AND    PARASITES. 

Toxic  symptoms  from  causes  arising  within  the  body,  either  from 
fermentative  or  putrefactive  changes  of  the  food  within  the  intestinal 
tract,  or  from  micro-organisms  causing  infectious  diseases,  septicaemia, 
saprsemia,  and  the  like,  have  been  referred  to  in  other  chapters,  espe- 
cially those  on  Diseases  of  the  Blood,  the  Acute  Infectious  Diseases, 
and  Gastro-Intestinal  Affections  and  Fevers.  In  this  section  will  be 
considered  only  those  disorders  due  to  poisons  or  parasites,  the 
morbid  phenomena  of  which  are  clearly  occasioned  by  causes  intro- 
duced into  the  system  from  without. 

POISONS. 

Cases  of  poisoning  may  arise  from  accident,  attempt  at  suicide,  or 
criminal  intent.  It  is  only  intended  here  to  set  forth  the  main  signs 
by  which  the  most  common  poisons  may  be  recognized  and  distin- 
guished. For  this  purpose  it  will  be  convenient  to  consider  the  cases 
as  divided  mto  acute  and  chronic,  subdividing  these  classes  according 
to  the  character  and  effects  of  the  different  substances. 

Acute  Poisoning. 

The  attack  comes  on  suddenly,  the  patient,  previously  in  good 
health,  having  taken  some  food,  drink,  or  medicine  which  has  been 
followed  by  the  severe  symptoms.  It  is  always,  in  a  case  of  sus- 
pected poisoning,  of  the  utmost  importance  to  be  able  to  make  out 
these  points. 

Irritant  Poisons. — The  chief  articles  which  give  rise  to  acute 
poisoning  belong  to  the  class  of  irritant  poisons.  The  symptoms  are 
generally  those  of  acute  gastritis,  attended  often  with  more  or  less 
inflammation  of  the  mouth,  the  fauces,  and  the  oesophagus.  Some- 
times the  air-passages  may  be  involved,  either  directly  or  by  sympathy, 
and  we  find  hoarseness  and  cough.  Convulsions  are  occasionally 
observed,  and  collapse  is  apt  to  occur  sooner  or  later. 

The  acute  pain,  the  tenderness,  and  the  vomiting  come  on  shortly 
after  a  meal,  or  at  least  after  something  has  been  swallowed.     This 

893 


g94  MEDICAL   DIAGNOSIS. 

distinguishes  the  acute  gastritis  caused  by  poisons  from  idiopathic 
acute  gastritis  or  from  acute  gastric  catarrh.  Sometimes  several  per- 
sons are  similarly  affected, — a  circumstance  always  strongly  in  favor 
of  the  idea  of  poisoning.  From  perforation  of  the  stomach  or  intestines, 
irritant  poisoning  is  discriminated  by  noting  that  the  acute  signs  in 
the  former  case  follow  upon  the  manifestations  of  some  gastric  or 
intestinal  disorder ;  and  the  attending  phenomena  of  collapse  are  not, 
as  in  poisoning,  associated  with  cramps  or  convulsions.  Cholera 
morbus  is  separated  by  the  history  of  the  case,  by  the  absence  of 
epigastric  tenderness,  and  by  the  purging  and  vomiting  often  coming 
on  simultaneously.  Cholera  resembles  poisoning  in  the  suddenness 
and  the  violence  of  the  attack,  but  is  distinguished  by  the  rice-water 
discharges  and  by  its  epidemic  character.  Bacteriological  examina- 
tion of  the  stools  also  affords  a  means  of  diagnosis.  In  strangulated 
hernia,  the  comparatively  gradual  onset,  the  pain,  the  tumor,  and  the 
constipation  will  be  significant.  As  regards  the  separation  of  cases^of 
poisoning  in  which  blood  is  ejected,  from  ordinary  hemorrhage  from 
the  stomach,  we  fmd  that  pain  and  purging  are  both  absent  in  the 
latter,  while  in  irritant  poisoning  they  are  well-marked  symptoms. 

Let  us  now  examine  some  special  poisons.  Strong  acids  are 
sometimes  used  in  self-destruction.  Nitric  acid  colors  the  lips  and 
mouth  orange-yellow  wherever  it  touches  them.  Sidphtiric  acid  stains 
the  skin  or  mucous  membrane  white  or  even  dark  gray ;  the  pain  is 
excessive,  and  nervous  symptoms  are  not  infrequent.  If  the  vomited 
matter  be  mixed  with  a  solution  of  barium  nitrate,  a  dense  white  pre- 
cipitate of  barium  sulphate  is  thrown  down.  Hydrochloric  acid  is 
less  irritant  and  corrosive  than  sulphuric  acid ;  in  the  ejected  matter 
silver  nitrate  produces  a  copious  white  precipitate  insoluble  in  nitric 
acid.  Oxalic  acid,  when  concentrated,  is  rapidly  fatal.  The  irritant 
effects  are  those  of  the  mineral  acids  ;  but  we  also  meet  with  dyspnoea 
and  with  nervous  phenomena,  such  as  anaesthesia,  parsesthesia, 
palsies,  and  convulsions. 

The  strong  alkalies,  when  taken  into  the  stomach,  cause  inflamma- 
tion of  the  organ  and  of  the  fauces  and  the  oesophagus.  Should  the 
case  end  in  recovery,  thickening  of  the  oesophagus  is  apt  to  occur. 
Ammonia  may  also  induce  severe  nervous  symptoms,  similar  to  those 
of  tetanus  ;  its  vapor  sometimes  acts  powerfully  on  the  air-passages, 
producing  harassing  cough.  Potassium  and  sodium  hydroxides — com- 
monly known  as  caustic  potash  and  caustic  soda — give  rise  to  violent 
local  inflammation  in  the  mouth,  oesophagus,  and  stomach.  The 
vomited  matter  has  an  alkaline  reaction.  Potassium  nitrate  is  a  strong 
<;ardiac  sedative. 


POISONS  AND  PARASITES.  895 

Potassium  iodide,  iodine,  bromine,  and  chlorine  are  all  capalDle  of 
destroying  life  by  their  intensely  irritant  effect. 

Phosphorus,  which  is  not  infrequently  taken  as  a  poison,  imparts 
to  the  breath,  to  the  faeces,  and  even  to  the  urine  an  alliaceous  smell, 
and  may  make  them  luminous  in  the  dark.  It  acts  as  an  irritant, 
causing  obstinate  vomiting  and  purging,  pain  at  the  epigastrium,  rapid, 
weak  pulse,  jaundice,  and  imquenchable  thirst.  The  local  pain  and 
inflammation  are  usually  extreme,  and  collapse,  with  or  without  con- 
vulsions, comes  on  early.  In  some  cases  painful  cramps  in  the  limbs 
occur,  and  various  disturbances  of  sensibility,  and,  later,  violent  de- 
lirium and  convulsions,  eventuating  in  coma  and  in  death.  In  other 
cases  hemorrhage  is  a  striking  feature,  the  blood  is  very  fluid,  and 
issues  from  all  the  passages,  and  petechiae  form  beneath  the  skin. 
The  temperature  remains  normal  until  near  death.  The  pulse  be- 
comes feeble  and  small ;  the  first  sound  of  the  heart  almost  disap- 
pears. Jaundice  is  a  constant  symptom ;  it  seldom,  however,  comes 
on  before  the  third  day,  and  is  rarely  intense ;  it  may  be  associated 
with  urticaria.  The  spleen  increases  in  size  simultaneously  with  the 
liver.  The  urine  becomes  very  scanty.  Albumin,  blood,  and  casts 
are  occasionally  present ;  biliary  coloring-matter  is  usually  met  with  ; 
urea  is  defective  ;  peptonuria  is  observed.  In  cases  of  phosphorus 
poisoning,  acute  and  extreme  fatty  degeneration  of  the  tissues  hap- 
pens. It  occurs  with  astonishing  rapidity.  It  has  been  seen,  in  the 
bodies  of  persons  poisoned  by  phosphorus,  within  forty-eight  hours, 
and  has  been  found  to  affect  the  heart,  the  smaller  blood-vessels  and 
capillaries,  the  liver,  the  kidneys,  the  glands  of  the  stomach,  and  the 
voluntary  muscles  ;^  the  liver  is  principally  implicated. 

Various  compounds  of  'potassium,  copper,  zinc,  silver,  lead,  and  iron 
occasionally  cause  death.  They  act,  for  the  most  part,  as  irritants 
merely  ;  but  some  of  them  are  powerfully  astringent,  and  even  caustic, 
as,  for  instance,  zinc  chloride  or  silver  nitrate.  If  the  toxical  phe- 
nomena are  due  to  the  nitrate  of  silver,  the  staining  of  the  lips  may 
afford  a  clue  to  the  nature  of  the  case.  There  are  no  really  distinc- 
tive symptoms  produced  by  large  doses  of  arsenic,  of  antimony,  of 
mercury,  or  of  their  compounds,  which  are  among  the  best  known  of 
irritant  poisons  :  the  peculiar  effects  of  each  of  these  substances,  when 
insidiously  introduced  into  the  economy,  will  be  presently  mentioned. 
In  (icide  arsenical  poisoning,  besides  the  pain  and  the  gastro-enteric 
symptoms,  convulsions,  delirium,  palsies,  and  bloody  or  albuminous 
urine  have  been  specially  noticed.     Arsenical  poisoning  is  a  very  com- 

^  T;ii'(li(iu,  Ktuilc  iii(''(lic<i-l(''fi:ilp  sur  rEinpoisonnemeiit,  1867.  p.  445. 


896  MEDICAL  DIAGNOSIS. 

mon  form  of  self-destruction.  It  is  also  observed  among  those  who 
accidentally  take  Scheele's  green,  or  among  children  who  swallow 
arsenical  paints.  There  is  in  the  internal  organs  a  fatty  degeneration 
similar  to  that  in  phosphorus  poisoning.  In  the  recognition  of  the 
cause  of  the  symptoms,  Reinsch's  test,  applied  to  the  vomited  matter, 
is  very  convenient  and  satisfactory.  In  poisoning  by  corrosive  subli- 
mate, epigastric  pain,  vomiting,  diarrhoea,  bloody  stools,  and  finally 
collapse,  are  met  with. 

Among  animal  substances,  cantharides  has  sometimes  been  pro- 
ductive of  poisonous  effects ;  strangury,  bloody  urine,  albuminuria, 
more  permanent  than  that  produced  by  turpentine,  priapism,  and 
spasm  of  the  glottis,  are  the  most  marked  symptoms ;  while  the 
shining  green  particles  of  the  drug,  if  taken  in  substance,  have  been 
detected  in  the  vomited  matters. 

Sausage,  milk,  cheese,  eggs,  especially  in  articles  of  confectionery, 
such  as  cream  puffs,  frequently  produce  violent  symptoms  suggesting 
some  of  the  more  powerful  irritants,  although  chemical  examination 
fails  to  reveal  any  mineral  poison.  The  main  cause  of  these  actions 
is  that  under  the  influence  of  certain  micro-organisms  the  albuminous 
matters  undergo  rapid  decomposition,  producing  nitrogenous  bodies, 
among  which  one  has  been  identified  as  a  diazobenzene  compound. 
Vaughan  originally  called  this  body  tyrotoxicon, — cheese  poison.  It 
is  highly  poisonous,  but  also  very  unstable.  It  is  produced  early  in 
the  decay  of  the  albuminous  articles,  and  is  decomposed  subsequently. 
We  can,  therefore,  understand  why  articles  of  food  may  be  less  irri- 
tating, when  decidedly  decomposed  than  when  decomposition  has  just 
set  in.  Besides  the  signs  of  gastro-intestinal  irritation,  vertigo,  head- 
ache, marked  anxiety,  and  muscular  weakness  have  been  noticed 
among  the  effects  of  these  ptomaines. 

The  vegetable  irritants  are  mainly  articles  commonly  used  as  pur- 
gatives. Thus,  elaterium,  aloes,  colocynth,  and  colchicum  have  all 
proved  fatal  when  taken  too  freely.  The  symptoms  do  not  differ 
materially  from  those  caused  by  other  poisons  of  this  class.  To- 
bacco and  lobelia  are  powerful  local  excitants,  occasioning  emesis  and 
purging,  with  a  speedy  collapse  of  the  system.  The  former,  when 
the  nicotine  produces  acute  symptoms  of  poisoning,  gives  rise  also  to 
salivation,  cold  sweats,  slow  pulse,  colicky  pains,  and  at  times  convul- 
sions. Savin  not  only  produces  inflammation  of  the  alimentary  canal, 
but  is  apt  also  to  give  rise  to  strangury  ;  it  is  most  frequently  resorted 
to  with  the  view  of  bringing  on  abortion.  Ergot  is  also  used  for  the 
same  purpose  ;  the  most  striking  symptoms  of  acute  ergot  poisoning 
are    colic,  vomiting,  diarrhoea,  increased    salivation,  retardation   and 


POISONS  AND  PARASITES.  897 

weakening  of  pulse,  muscular  weakness,  and,  in  severe  instances, 
stupor.     The  poisoning  rarely  ends  fatally. 

Poisonous  fungi^  such  as  the  fly  fungus,  which  are  eaten  by  mistake 
for  mushrooms,  produce  violent  symptoms  of  irritant  poisoning  at- 
tended with  other  phenomena.  The  poisonous  agent  in  the  fly  fungus 
is  muscarine,  and  it  gives  rise  to  vomiting,  violent  colic,  and  diarrhoea, 
besides  slowing  of  the  pulse  and  the  breathing,  and  violent  excitement 
followed  by  stupor  and  somnolency.  The  case  generally  lasts  two  or 
three  days,  and  may  then  end  in  recovery  or  in  collapse ;  but  it  may 
terminate  fatally  in  six  or  seven  hours,  haemoglobinuria  being  among 
the  symptoms.  Finding  the  fungi  in  the  vomited  matter  or  in  the 
stools  greatly  facilitates  the  diagnosis.  Other  poisonous  fungi  produce 
much  the  same  symptoms  ;  and  even  the  usually  eaten  and  innocuous 
kinds  of  mushrooms  may,  if  at  all  spoiled,  or  in  certain  individuals,  or 
when  eaten  raw,  occasion  similar  symptoms. 

Narcotic  Poisoning. — The  symptoms  of  narcotic  poisoning  vary 
more,  according  to  the  special  article  taken,  than  those  caused  by 
irritants.  Narcotic  poisons  affect  chiefly  the  nervous  system  and  the 
circulation.  Many  of  them  produce  phenomena  like  apoplexy  and 
intoxication,  from  which  they  need  to  be  carefully  distinguished. 
Narcotic  poisoning  is,  for  the  most  part,  of  the  acute  form. 

Opium  is  by  far  the  most  important  of  narcotic  poisons.  It  in- 
duces giddiness,  stupor,  and  lethargic  sleep,  from  which,  however,  the 
patient  can  at  first  be  roused,  if  sharply  spoken  to.  Subsequently 
this  sleep  deepens  into  coma  and  cannot  be  broken ;  the  skin  is 
relaxed  and  perspiring ;  the  face  is  usually  pale ;  the  pupils  are 
contracted  and  insensible  to  light ;  erections  of  the  penis  are  com- 
mon. A  more  or  less  evident  odor  of  opium  may  often  be  perceived 
about  the  person  or  on  the  breath.  No  distinction  can  be  drawn  be- 
tween the  effects  of  different  forms  of  this  poison :  the  stronger  the 
preparation,  however,  the  more  marked  and  the  more  rapid  will  be 
the  progress  of  the  case.  Morphine,  codeine,  narcotine,  and  the  other 
alkaloids  give  rise  to  similar  symptoms,  but  the  smell  of  opium  is 
absent ;  convulsions  are  most  likely  to  occur  from  narcotine,  papav- 
erine, and  thebaine. 

The  diagnosis  of  opium  poisoning  from  apoplexy  and  from  the 
coma  of  urcemia  has  been  discussed  in  a  former  chapter.  We  may 
merely  recall  that  the  contracted  pupil  caused  by  opium  is  of  very 
great  significance,  and  does  not,  with  the  exceptions  there  referred  to, 
exist  in  the  other  states.  Moreover,  the  coma  in  apoplexy  is  at  once 
developed ;  while  in  narcotic  poisoning  it  is  not  sudden,  but  is  pre- 
ceded by  drowsiness  or  stupor,  which   gradually  passes  into  coma. 

•50 


898  MEDICAL  DIAGNOSIS. 

These  phenomena  occur  also  in  the  same  sequence  in  ursemia ;  but 
they  are  even  slower  in  their  progress,  and  are  frequently  associated 
with  convulsions  and  with  markedly  albuminous  urine  and  dropsy. 

From  acute  alcoholism  we  discriminate  opium  poisonmg  chiefly 
by  the  absence  of  the  alcoholic  odor,  the  slow  respiration,  and  the 
presence  of  morphine  in  the  urine.  The  characteristic  smell  of  chlo- 
roform^ the  great  pallor  of  the  countenance,  the  complete  and  speedy 
collapse,  and  the  absence  of  contracted  pupils  distinguish  chloroform 
poisoning  from  opium  poisoning.  It  is  the  same  with  ether.  Poison- 
ing by  chloroform  or  by  ether  is  mostly  encountered  during  surgical 
operations. 

Chloral,  in  excessive  doses,  produces  heavy  sleep,  with  contracted 
pupils,  but  they  dilate  on  awaking.^  There  is  some  reduction  of  tem- 
perature, with  rapid  pulse,  giddiness,  inability  to  walk  straight,  double 
vision,  and  headache,  in  cases  in  which  consciousness,  sensibility,  and 
muscular  power  have  not  been  entirely  suspended  by  the  drug. 
Weak  action  of  the  heart  is  another  of  the  dangers  of  chloral  poison- 
ing, and  I  have  known  a  dilated  heart  almost  paralyzed  even  by  small 
doses.  In  some  instances  a  stage  of  excitement  like  alcoholic  intoxi- 
cation precedes  the  narcotism.  The  urine  may  or  may  not  contain 
sugar .^  Chloral  itself  simulates  sugar  in  the  results  of  the  copper  and 
bismuth  tests.  It  is  occasionally  used  for  drugging  liquor  for  purposes 
of  robbery  or  rape.  . 

Be)izin,  when  taken  internally,  occasions  noises  in  the  head,  mus- 
cular tremor  and  twitchings,  and  deep  sleep  ;  but  the  narcotic  depres- 
sion ends  in  recovery. 

Alcohol,  if  taken  in  large  quantities  and  not  much  diluted,  gives 
rise  to  symptoms  like  those  caused  by  opium.  The  eye  is  injected 
and  the  seat  of  ecchymosis  ;  the  pupils  are,  as  a  rule,  dilated  and 
very  sluggish  ;  the  breathing  is  irregular  and  stertorous ;  the  temper- 
ature lowered ;  the  insensibility  may  alternate  with  convulsions ;  the 
breath  has  a  strong  smell  of  alcohol  or  may  be  quite  free  from  spirit- 
uous odor.  This  absence  of  odor  of  the  breath,  although  not  usual, 
may  give  rise  to  a  confusion  between  alcoholic  poisoning  and  apoplexy, 
and  the  discrimination  of  these  conditions  must  then  depend  in  some 
measure  upon  evidence  furnished  by  the  history  of  the  occurrence  of 
the  insensibility,  and  by  the  presence  or  absence  of  palsy. 

Alcohol  may  readily  be  detected  in  the  urine.     Woodbury's^  mod- 

^  Taylor  on  Poisons,  3d  edit.,  1875. 

'^  See  a  case  of  mine  recorded  in  a  Clinical  Lecture  on  Chloral  Poisoning, 
Phila.  Med.  Times,  March,  1883. 

*  Philadelphia  Medical  Times,  March,  1883. 


POISONS  AND  PARASITES.  899 

ification  of  Ainstie's  test  is  very  convenient.  Into  a  tube  containing 
a  gramme  of  sulphuric  acid,  which  should  be  colorless  or  nearly  so, 
twice  as  much  of  the  urine  to  be  tested  is  poured.  A  small  crystal 
of  bichromate  of  potassium  is  then  dropped  in,  and  the  liquid  slowly 
mixed  by  rotating  the  test-tube.  If  alcohol  be  present  in  proportion 
as  large  as  two  or  three  parts  per  thousand,  a  permanent  green  dis- 
coloration will  result ;  if  there  be  less  than  this,  the  liquid  will  remain 
of  ruby  color.  Chloral  in  the  urine  does  not  produce  the  peculiar 
reaction. 

Belladonna^  or  its  active  principle,  atropine^  and  hyoscyamus  pro- 
duce more  marked  excitement  of  the  brain  than  opium  does,  causing 
delirium  of  active  kind,  perhaps  with  convulsions.  The  pupils  are 
greatly  dilated,  and  vision  is  singularly  deranged ;  there  is  intense 
thirst,  with  great  dryness,  redness,  spasm,  and  burning  in  the  throat ; 
the  breathing  is  rapid,  thus  differing  from  apoplectic  conditions.  The 
temperature  is  always  lowered ;  the  pulse  becomes  quick  and  com- 
pressible ;  a  scarlet  efflorescence  may  happen.  The  surest  test  of 
poisoning  by  atropine  is  to  take  some  of  the  urine  passed,  and  with 
it  to  dilate  the  pupil  in  the  eye  of  a  cat. 

Conium  occasions  stupor,  paralyzes  the  muscular  system,  and 
dilates  the  pupils  ;  there  is  dyspnoea,  while  the  heart,  though  rendered 
slower,  is  not  much  affected.  Convulsions  may  come  on.  These 
help  to  distinguish  conium  poisoning  from  curare  poisoning,  which  it 
much  resembles.     In  the  latter,  however,  the  palsy  is  greater. 

Carbolic  acid,  if  taken  in  poisonous  doses,  produces  rapidly  dan- 
gerous symptoms,  which  may  terminate  in  death  in  a  few  hours. 
Vomiting,  slow  pulse,  noisy  breathing,  loss  of  consciousness,  deepen- 
ing into  profound  coma,  abolition  of  reflex  movements,  cool  skin, 
suiDpression  of  urine,  are  the  main  symptoms.  When  the  urine  is 
obtained,  it  is  of  dark-green  or  black  color ;  this  and  the  odor  of  car- 
bolic acid  about  the  patient  are  significant  features.  The  discolored 
urine  contains  blood-corpuscles,  epithelium,  and  tube-casts. 

Aniline  poisoning  is  met  with  among  the  workers  in  factories  in 
which  the  aniline  colors  are  made.  It  is  the  breathing  of  the  aniline 
vapor,  especially,  which  occasions  the  toxic  effect.  Vertigo,  headache, 
a  sense  of  suffocation,  vomiting,  anaesthesia,  pain  in  the  extremities, 
somnolency,  and  a  dark  cyanotic  discoloration  of  the  ears,  the  nails, 
and  the  mucous  membrane  of  the  nose,  have  been  especially  noticed. 

Hydrocyanic  ov  prussic  acid  usually  leads  to  convulsive  contrac- 
tions of  the  muscles  of  the  limbs  and  trunk,  and  destroys  life  by 
stopping  the  circulation  and  the  respiration.  Sometimes  the  odor 
of  the  acid,  resembling  that  of  bitter  almonds,  is  perceptible  in  the 


900  MEDICAL  DIAGNOSIS. 

breath ;  but  too  much  reliance  must  not  be  placed  upon  this  point. 
Unfortunately,  the  diagnosis  of  this  poison  has  generally  to  be  made 
after  death,  for  medico-legal  purposes. 

The  gases  arising  from  burning  coal  and  charcoal  may  cause  death 
by  asphyxia ;  and  a  knowledge  of  this  fact  has,  particularly  in  France, 
led  to  many  suicides.  In  those  cases  in  which  the  asphyxia  has  not  a 
fatal  termination,  yet  has  been  decided,  disorders  in  the  peripheral 
nerves  may  manifest  themselves,  either  by  the  signs  of  neuritis,  or  by 
pain  and  swelling  simulating  a  phlegmon,  or  by  vesicular  eruptions  in 
the  course  of  an  affected  nerve.  The  peripheral  disturbances  may 
appear  at  once  or  not  until  after  some  days.  The  signs  of  disorder  of 
the  vasomotor  nerves  do  not  last  long ;  those  of  the  motor  or  sensi- 
tive nerves  have  a  longer  duration ;  the  complaint  induced  may  be 
incurable,  extending  from  the  centre  to  the  periphery,  or  in  the  re- 
verse direction  ;  or,  lastly,  the  affection  may  cause  an  acute  ascending 
paralysis.^ 

The  poisonous  action  in  these  cases  is  due  largely  to  carbonic 
oxide,  carbon  monoxide,  a  gas  which  has  a  strong  affinity  for  haemo- 
globin, and  suspends  the  oxygen-absorbing  function  of  the  blood,  thus 
establishing  a  chemical  asphyxia.  The  gas,  being  non-irritating,. may 
be  inhaled  without  exciting  immediate  suspicion.  The  so-called  water- 
gas  contains  large  amounts  of  carbon  monoxide.  Experiment  has 
shown  that  such  gas  is  much  more  dangerous  when  inhaled  than  the 
ordinary  illuminating  gas,  which  consists  almost  entirely  of  compounds 
of  carbon  and  hydrogen.  In  poisoning  by  carbonic  acid,  carbon 
dioxide,  there  is  much  greater  disturbance  of  breathing  than  in  car- 
bonic oxide  poisoning. 

Antipyrin  given  in  large  doses  may  produce  extreme  lowering  of 
the  temperature  and  collapse.  Cyanosis,  frequency  of  respiration  and 
of  pulse,  dyspnoea,  a  feeling  of  extreme  heat  over  the  body,  and  an 
erythematous,  urticarial,  or  measly  eruption,  have  also  been  noticed. 
In  one  instance  reported,  the  use  of  the  drug  led  to  the  formation  of 
membranes  in  the  mouth,  and  to  symptoms  of  laryngeal  spasm,  which 
was  not  the  case  when  phenacetin,  antifebrin,  or  exalgin  was  substi- 
tuted.^ 

Petroleum  taken  in  excessive  quantities  produces  giddiness,  faint- 
ness,  and  palpitation,  with  tonic  and  clonic  convulsions,  contracted 
pupils,  hot  skin,  and  slow  pulse  ;  it  does  not  occasion  either  stupor  or 
vomiting  ;  the  urine  has  an  aromatic  odor.     Recovery  is  the  rule. 


1  Leudet,  Arch.  Gen.  de  Med.,  May,  1865. 

^  Salinger,  Amer.  Journ.  Med.  Sci.,  May,  1890. 


POISONS  AND  PARASITES.  901 

Nitroglycerin  occasions  a  throbbing  headache  increased  by  motion, 
mental  confusion,  flushing  of  the  face,  pulsations  all  over  the  body, 
arterial  relaxation,  and  collapse. 

Following  these  poisons,  which  are  in  the  main  narcotic  poisons 
or  belong  to  the  group  of  poisonous  carbon  compounds,  we  shall  ex- 
amine some  forms  of  acute  poisoning  produced  by  certain  powerful 
vegetable  poisons. 

Aconite  has  a  strongly  sedative  influence  upon  the  action  of  the 
heart,  brain,  and  spinal  cord,  as  well  as  an  irritant  action  upon  the 
alimentary  canal ;  slow  pulse,  giddiness,  delirium,  numbness,  and 
tingling  of  the  skin,  loss  of  power  in  the  legs,  with  formication,  tingling 
of  the  tongue,  vomiting,  and  purging,  are  followed  by  syncope  and 
death. 

Digitalis  causes  dilatation  of  the  pupil,  generally  with  vomiting, 
often  with  purging  and  with  headache,  giddiness,  and  suppression  of 
urine ;  its  chief  effect,  however,  is  upon  the  pulse,  which  is  strikingly 
lessened  both  in  frequency  and  in  force,  and  becomes  irregular ;  the 
action  of  the  heart,  too,  becomes  weak,  and  blood-pressure  is  dimin- 
ished. The  skin  is  cold,  pale,  and  covered  with  sweat ;  the  mind  is 
generally  clear,  though  there  are  great  lassitude,  with  muscular  debil- 
ity, a  tendency  to  sleep,  and  at  times  convulsions.  The  action  of  the 
poison  generally  extends  over  days.  Veratrum  viride  resembles  digi- 
talis in  its  action.  It  markedly  reduces  the  pulse,  and  gives  rise  to 
vomiting,  to  great  prostration;  and  to  irregular  breathing.  The  tem- 
perature is  much  lowered.  Poisoning  by  jaborandi  or  pilocarpine 
produces  profuse  sweating  and  salivation,  vomiting,  diarrhoea,  respira- 
tory and  cardiac  distress,  dimness  of  vision,  and  contracted  pupils. 

Calabar  bean  acts  as  a  direct  sedative  to  the  spinal  marrow,  par- 
ticularly to  the  medulla,  and  produces  great  muscular  debility  or  re- 
laxation, or  even  paralysis,  extending  to  the  heart  and  respiratory 
muscles.  The  mental  faculties  remain  unaffected,  and  in  this  its 
action  differs  from  that  of  the  cerebral  sedatives.  It  is,  however, 
irritant  to  the  alimentary  canal,  causing  vomiting  or  purging,  a  pecu- 
liar epigastric  sensation  is  generally  experienced,  and  increased  saliva- 
tion is  met  with.  Calabar  bean  contracts  the  pupil  and  also  the  ciliary  . 
muscle,  thus  making  the  eye  myopic.  The  condition  of  the  eye  is  the 
main  diagnostic  sign  that  distinguishes  poisoning  by  calabar  bean  from 
poisoning  by  curare  or  by  conium. 

Strychnine  and  brucine^  the  active  principles  of  nux  vomica  and  of 
allied  .plants,  give  rise  to  phenomena  strongly,  resembling  those  of 
tetanus.  A  very  short  time,  however, — from  a  few  minutes  to  an  hour 
or  two, — will  determine  the  issue  of  a  case  of  poisoning;  while  teta- 


902  MEDICAL  DIAGNOSIS. 

nus  may  run  a  course  of  several  weeks.  The  first  symptom  of  strych- 
nine poisoning  is  a  sense  of  suffocation  and  dyspnoea,  followed  by 
spasms  of  the  respiratory  muscles,  by  starting  and  twitching  and 
rigidity  of  the  arms  and  legs,  especially  of  the  extensor  muscles,  but 
not  by  lock-jaw ;  tetanus,  on  the  other  hand,  comes  on  with  setting 
or  locking  of  the  jaws,  and  the  limbs  are  not  at  first  affected  with 
spasms  ;  indeed,  the  arms  remain  throughout  nearly  free  from  them, 
and  the  paroxysms  of  spasm  do  not  follow  one  another  so  rapidly  as 
in  strychnine  poisoning,  and  are  of  shorter  duration.  Again,  idio- 
pathic tetanus  is  extremely  rare  ;  almost  always  there  has  been  some 
wound  or  injury  as  a  proximate  cause  of  the  malady.  But  we  need 
not  pursue  these  points  of  diagnosis  farther:  they  have  been  men- 
tioned in  connection  with  tetanus.  From  epilepsy  strychnine  poison- 
ing differs  by  the  unimpaired  consciousness  ;  from  hydrophobia,  by  the 
absence  of  spasm  of  the  oesophagus  and  of  the  terrible  dysphagia. 

Picrotoxin  also  produces  convulsions  which  may  be  mistaken  for 
those  caused  by  strychnine.  But  they  are  not  of  a  reflex  nature,  and 
reflex  spasms  are  not  induced.  The  breathing  is  rapid  ;  the  contrac- 
tion of  the  heart  is  retarded ;  there  are  often  somnolence  and  muscular 
debility.     A  scarlatinal  eruption  has  been  noticed. 

Chronic  Poisoning. 

When  the  patient  has  been  subjected  to  the  continuous  action  of  a 
noxious  substance,  the  case  is  said  to  be  one  of  chronic  or  slow  poi- 
soning. Any  of  the  irritant  poisons,  given  in  small  and  repeated  doses 
will  keep  up  a  morbid  condition  of  the  stomach  and  bowels  much  like 
ordinary  chronic  inflammation. 

The  narcotics,  taken  in  the  same  manner,  act  upon  the  vasomotor 
nerves  and  the  cerebro-spinal  system,  and  through  this  upon  the  ali- 
mentary canal,  so  deranging  digestion  and  nutrition  as  even  indirectly 
to  cause  death.  Opium  is  the  most  important  of  the  articles  thus 
used ;  it  is  often  administered  to  infants  for  the  purpose  of  quieting 
their  cries,  and  the  frequent  repetition  of  the  dose  induces  a  series  of 
phenomena  closely  aUied  to  those  observed  in  the  adult.  With  the 
effects,  oil  the  mind,  of  opium  taken  persistently  for  the  sake  of  intoxi- 
cation, the  reading  world  is  familiar  through  the  published  experiences 
of  De  Quincey  and  of  Coleridge. 

The  habit  is  here  and  in  Europe  generally  acquired  only  by  persons 
who  have  begun  the  practice  for  the  relief  of  some  painful  affection ;, 
in  the  East,  opium  is  used  much  more  commonly,  and,  in  many  Ori- 
ental countries,  to  smoke  it  is  a  favorite  amusement.     Those  who  em- 
ploy it  constantly  are  pale,  or  have  a  sallow,  haggard  countenance  and 


POISONS  AND  PARASITES.  903 

a  dull  eye.  They  lose  their  power  of  will  and  their  energy,  and  are 
troubled  by  loss  of  appetite,  giddiness,  anomalous  neuralgic  pains, 
sleeplessness,  and  low  spirits,  which  they  relieve  by  resorting  to  the 
opiate.  Though,  in  spite  of  the  pernicious  custom,  the  general  health 
may  remain  for  many  years  good,  yet  sooner  or  later  it  gives  way,  and 
the  opium-eater  dies  worn  out ;  or  death  may  be  the  consequence  of 
disease  of  the  liver,  of  palsy,  or  of  inveterate  diarrhoea,  produced  by 
long  addiction  to  the  vice.  Persons  who  consume  large  quantities  of 
opium  are  apt  to  have,  from  time  to  time,  attacks  of  extreme  nervous 
prostration,  attended,  perhaps,  with  violent  headache,  and  requiring 
free  stimulation  for  their  relief.  The  employment  of  morphine  hypo- 
dermically  has  become  an  alarmingly  frequent  form  of  the  opium 
habit,  especially  among  members  of  the  medical  profession.  Besides 
the  general  symptoms  of  chronic  opium  poisoning,  we  may  have  ex- 
tensive ulcers  and  other  local  signs  of  skin  irritation  to  deal  with. 
* 
Ether  and  chloroform,  habitually  made  use  of,  also  cause  serious 

disturbance  of  the  nervous  system ;  and  so  does  alcohol.  The  abuse 
of  spirituous  liquors  gives  rise  to  a  disorder  of  the  mental,  motor,  and 
sensory  functions,  producing  sleeplessness,  headache,  giddiness,  hallu- 
cinations, imbecility,  ansesthesia,  disordered  vision,  and  palsies.  There 
results  a  fine  irregular  tremor,  affecting  particularly  the  hands,  lips, 
and  tongue,  and  occurring  only  on  attempted  movement.  Multiple 
neuritis  is  also  a  common  sequel.  Chronic  alcoholism  also  occasions  a 
sensation  of  choking,  a  diminished  vitality,  a  persistent  catarrh  of  the 
gastro-intestinal  membrane,  a  tendency  to  fatty  degeneration,  espe- 
cially of  the  liver  and  kidneys  ;  in  short,  the  symptoms  met  with  in 
drunkards  and  constituting  the  state  described  as  chronic  alcoholism. 
Chronic  alcoholism  in  the  parent  may  produce  epilepsy  in  the  child. 

Chloral  has  proved,  like  opium  and  like  chloroform,  a  very  fasci- 
nating drug  to  many.  The  chief  symptoms  of  chronic  chloral  poi- 
soning are  digestive  disorders,  irregular  breathing,  impairment  of 
intelligence  and  of  memory,  persistent  drowsiness,  almost  stupor, 
striking  enfeeblement  of  will,  want  of  power  in  the  legs  amounting  at 
times  to  paralysis,  and  occasional  tremor.  Defective  co-ordination 
with  marked  ataxic  symptoms,  similar  to  those  of  locomotor  ataxia, 
and  loss  of  knee-jerk,  occur  from  the  habit  of  taking  chloral.^  I  have 
known  delirium  tremens  to  follow  its  use,  when  large  quantities  of  it 
had  been  taken  and  the  medicine  stopped.  Feeble,  irregular  action  of 
the  heart,  and  sweating,  I  have  also  found  among  the  symptoms  of 

^  J.  C.  Wilson,  article  "Opium  Habit  and  Kindred  Affections,"  System  of 
Practical  Medicine  by  American  Autbors,  vol.  v. 


904  MEDICAL  DIAGNOSIS. 

chloral  poisoning.  An  erythematous  inflammation  of  the  skin  of  the 
fingers,  with  desquamation  and  ulceration  around  the  borders  of  the 
•nails,  has  been  pointed  out  as  a  result;^  and  various  forms  of  erup- 
tion, such  as  urticaria,  lichen,  and  purpurous  spots,  as  well  as  bed- 
sores, have  been  observed  after  its  prolonged  use. 

Paraldehyde  is  abused  like  chloral  and  morphine.      It  occasions, 
when  taken  habitually,  gastric  disorder,  diarrhcEa,  sleeplessness,  feeble  , 
circulation,  sweatmg,  and  delirium  tremens. 

Tobacco  used  in  excess  gives  rise  to  tremors,  to  giddiness,  to  ema- 
ciation, to  impaired  digestion,  and  to  intermittence  in  the  pulse,  with 
irregular  cardiac  action  and  palpitations,  which  may  become  very  an- 
noying and  originate  the  behef  of  an  organic  disease  of  the  heart. 
Like  the  persistent  abuse  of  alcoholic  drinks,  tobacco  may  occasion 
amaurosis  ;  an  insidious,  obstinate  form  of  otitis  is  developed  in  in- 
veterate smokers,  and  is  attended  with  very  minute  granulations  of 
the  pharynx,  nasal  fossEe,  tubes,  and  middle  ear.^  When  taken  in  large 
quantities  by  those  previously  unaccustomed  to  it,  tobacco  produces 
cohc,  diarrhoea,  weakness,  sleeplessness,  dull  hearmg,  vomiting,  diffi- 
culty in  breathing,  cold  sweats,  feeble  action  of  the  heart,  and  will  even 
cause  collapse  and  death.  The  peculiar  odor  of  tobacco  may  assist 
us  in  the  diagnosis  of  tobacco  poisoning ;  but  it  must  be  remembered 
that  this  may  attend  other  morbid  states  in  those  who  use  tobacco 
largely. 

Ergot,  long  continued,  particularly  when  taken  contained  in  im- 
pure flour,  gives  rise  to  the  well-characterized  disease,  chronic  ergot- 
ism. This  appears  mainly  in  two  forms  :  the  first  is  marked  by  con- 
vulsions with  disturbance  of  sensation  ;  the  second  by  gangrene  ;  both 
are  apt  to  show  themselves  in  epidemics.  In  the  convulsive  form 
there  is  at  first  formication,  which  lasts,  whether  attended  with  anaes- 
thesia or  not,  throughout  the  whole  illness.  Soon  muscular  tmtcliings 
and  cramps  followed  by  painful  contractions  happen,  and  the  con- 
vulsions may  become  general.  These  spasms  especially  affect  the 
flexors  of  the  arm,  and  unlike  those  of  strychnine,  they  are  not  reflex 
spasms.  There  is  no  fever ;  the  circulation  is  slow  and  feeble ;  the 
appetite  is  insatiable ;  we  find  nausea,  vomiting,  and  diarrhoea.  The 
disease  generally  lasts  one  or  two  months.  In  severe  cases  delirium 
occurs  as  a  precursor  to  death.  In  gangrenous  ergotism  the  same 
symptoms  happen  ;  but  in  addition  we  meet  with  gangrene  without 
fever  or  signs  of  inflammation.  The  gangrene  may  be  in  the  extremi- 
ties or  in  the  face. 

^  Smith,  Lancet,  vol.  ii.,  1871.  '^  Triquet,  Le  Brlert. 


POISONS  AND  PARASITES.  905 

•  Let  us  now  examine  some  of  the  features  of  slow  poisoning  by  the 
metals. 

Mercury,  in  any  of  its  preparations,  may  lead  to  clironic  poisoning. 
The  mouth  is  inflamed,  the  gums  are  sore  and  swollen,  the  salivary 
glands  act  inordinately,  and  the  breath  is  very  offensive.  Colicky 
pains,  diarrhoea  or  bloody  discharges,  as  well  as  acute  nephritis,  may 
occur.  Tremors  of  the  limbs  when  any  motion  is  attempted  are  par- 
ticularly frequent  in  cases  where  the  poison  lias  been  inhaled  in  the 
form  of  vapor ;  they  come  on  by  degrees,  and  are  associated  with  loss 
of  power  of  locomotion.  The  tremors  may  be  incessant  and  the 
movements  involuntary,  like  those  of  chorea,  and  so  rapid  as  to  pre- 
vent the  patient  from  obtaining  rest  at  night.^  In  some  cases  an 
eczematous  affection  is  observed.  Poisoning  by  mercury  is  generally 
the  result  of  the  exposure  to  its  action '  incidental  to  certain  occupa- 
tions, such  as  glass-plating,  gilding,  and  working  in  quicksilver-mines ; 
but  it  may  be  also  noticed  as  following  antiseptic  injections  of  corrosive 
sublimate. 

Lead  poisoning  iQ  by  no  means  uncommon  among  painters,  plumb- 
ers, type-setters,  and  other  workers  in  lead.  Sometimes  it  may  be 
caused  by  accidental  circumstances,  as  when  the  patient  has  drunk 
water  passed  through  leaden  pipes,  or  taken  snuff  which  has  been 
impregnated  with  lead  for  the  purpose  of  coloring  it.  Poisonous 
properties  are  also  acquired  by  snuff  wrapped  in  lead-foil ;  and  lead 
poisoning  has  been  observed  after  the  use  of  cosmetics,  and  among 
those  engaged  in  the  manufacture  of  lucifer  matches,  of  brushes,  of 
lace,  or  working  in  glass  enamel  or  glass  powder ;  ^  and  in  conse- 
quence of  food  adulteration,  especially  of  the  use  of  lead  chromate  to 
color  cakes.^ 

In  such  cases,  the  physician  may  have  to  depend  entirely  upon  a 
correct  appreciation  of  tlie  symptoms  for  the  diagnosis.  Pain  and  un- 
easiness in  the  course  of  the  colon,  constipation,  loss  of  appetite, 
anaemia,  weakness,  mental  depression,  and  emaciation  are  the  earlier 
signs,  A  metallic  taste  is  perceived ;  the  breath  is  fetid,  the  tongue 
pale  and  furred ;  the  gums  are  edged  with  a  narrow  blue  line  of  sul- 
phide of  lead,  deposited  mainly  outside  loops  of  blood-vessels. 
Colicky  pains  occur  from  time  to  time,  and  a  severe  and  long-con- 

^  As  in  a  case  reported  by  Taylor,  in  which  the  patient  died  from  the  effects  of 
the  poison,  without,  however,  having  presented  sahvation  or  mercurial  fetor  of  the 
breath,  or  a  blue  line  on  the  gums.     Guy's  Hospital  Reports,  3d  Series,  vol.  x. 

^  Lacharriere,  Arch.  Gen.  de  Med.,  Dec.  1859. 

*  Stewart,  Clinical  Analysis  of  Sixty-four  Cases  of  Poisoning  by  Lead  Chro- 
mate, Medical  News,  Dec.  31,  1887,  and  ibid..  Jan.  20,  1889. 


906  MEDICAL  DIAGNOSIS. 

tinned  attack  of  colic  may  form  the  culmination  of  the  disease.  The 
muscles  atrophy ;  electro-muscular  contractility  to  the  faradic  current 
is  greatly  diminished,  to  the  galvanic  current  it  is  frequently  unaltered 
or  increased ;  the  sensibility  of  the  skin  is  but  little  affected.  Occa- 
sionally wrist-drop  or  paralysis  of  the  extensor  muscles  of  the  fore- 
arms, the  well-known  phenomenon  of  lead  poisoning,  happens  among 
the  first  symptoms  ;  but  it  is  more  generahy  preceded  by  one  or  more 
attacks  of  colic.  The  right  arm  mostly  suffers  first.  We  also  find  at 
times  lesions  of  the  tendons  in  saturnine  palsy.  Yet  a  paralysis  of  the 
extensors  occurs  which  is  not  due  to  lead,  as  in  alcoholic  multiple 
neuritis. 

Another  manifestation  of  lead  poisoning  is  found  in  the  severe 
pains  in  the  joints  and  the  neighboring  muscles.  These  pains  have 
violent  exacerbations,  and  may  be  associated  with  cramps  of  the 
painful  muscles.  They  are  most  common  in  the  lower  extremity, 
especially  over  and  near  the  knee-joints.  There  are  no  signs  of  in- 
flammation of  the  affected  joints  and  muscles ;  pressure  tends  to  re- 
lieve the  pains. 

Sometimes,  in  cases  of  saturnine  poisoning,  there  is  evidence  of 
grave  cerebral  disorder :  epileptiform  convulsions,  attacks  resembling 
apoplexy,  or  general  tremors  and  extended  paralysis  of  the  muscles, 
with  acute  delirium,  inequality  of  the  pupil,  optic  neuritis,  retinal 
hemorrhages,  loss  of  sight,  and  other  signs  of  nervous  disturbance, 
are  noticed.  Of  course  the  diagnosis,  under  these  circumstances,  will 
be  materially  assisted  by  an  accurate  knowledge  of  the  previous  his- 
tory of  the  patient  as  regards  exposure  to  the  action  of  the  poison. 
The  tremors  are,  like  those  caused  by  mercury,  peculiar  in  ceasing 
when  the  limbs  are  supported  or  at  rest ;  they  are  increased  by  move- 
ment. There  may  be  tremor  in  the  muscles  of  the  face,  which,  how- 
ever, are  not  affected  by  paralysis.  Another  result  of  lead  poisoning 
is  that  it  leads  to  granular  degeneration  of  the  kidneys.  This  is  apt, 
again,  to  coexist  with  a  gouty  condition,  which,  as  Garrod  has  shown, 
is  one  of  the  results  of  the  absorption  of  lead.  But  the  kidney  affec- 
tion may  be  found  whether  or  not  the  joints  are  markedly  affected, 
and  may  exist  without  albuminous  urine.^ 

In  instances  in  which  the  symptoms  of  lead  poisoning  are  obscure 
or  conflicting,  we  may  search  for  lead  in  the  urine.  But  the  detection 
of  small  amounts  of  lead  cannot  be  undertaken  except  by  a  profes- 
sional chemist.  A  considerable  proportion  of  the  lead  is  eliminated 
by  the  bowels. 

^  Lancereaux,  Arch.  Gen.  de  Med.,  Dec.  1881. 


POISONS  AND  PARASITES.  907 

Copper-poisoning  gives  rise  to  dyspeptic  symptoms,  to  diuresis,  to 
loss  of  flesh,  to  lassitude  and  giddiness,  to  a  peculiar  greenish-blue 
perspiration,  and  to  a  green  line  on  the  gums  and  teeth.  It  is  said 
that  workmen  in  copper  are  singularly  insusceptible  to  cholera  or 
choleraic  diarrhcea,^  and  that  wounds  in  them  heal  with  extraordinary 
rapidity.  Copper  appears  to  be  somewhat  less  liable  than  mercury, 
lead,  arsenic,  or  antimony  to  cause  serious  chronic  poisoning,  possibly 
because  it  is  less  cumulative.  Small  amounts  of  copper  are  frequently 
present  in  the  liver  and  brain  of  man  and  some  of  the  lower  animals, 
also  in  some  articles  of  food.  Dr.  Leffmann  informs  me  that,  in  the 
examination  of  viscera  from  cases  of  lead  poisoning  which  occurred  in 
Philadelphia,  copper  in  minute  amounts  was  frequently  encountered, 
and  in  one  instance,  that  of  a  child  four  years  of  age,  an  appreciable 
quantity  was  obtained  from  a  portion  of  the  liver. 

Arsenic^  administered  in  small  doses  for  a  lengthened  period, 
produces  a  state  of  chronic  inflammation  of  the  alimentary  canal. 
Conjunctivitis,  oedema  of  the  face  and  the  limbs,  in  some  instances 
associated  with  albuminous  urine,  irritability  of  the  stomach,  diarrhcBa, 
sleeplessness,  increasing  weakness,  numbness,  formication,  alterations 
of  sensation,  and  even  paralysis,  mark  the  progress  of  these  cases  ; 
the  hair  and  the  nails  occasionally  fall  out,  and  there  is  much  frontal 
headache.  Similar  effects  are  noticed  to  follow  the  pernicious  habit 
of  arsenic-eating,  and  will  be  also  encountered  among  persons  em- 
ployed in  making  artificial  flowers  and  toys,  in  dyeing  cloths,  in  man- 
ufacturing and  hanging  green  wall-papers,  or  in  the  sublimation  of 
arsenical  ores ;  those,  too,  who  live  in  rooms  hung  with  papers  con- 
taining much  arsenic  have  exhibited  the  influences  of  the  poison.^ 
Besides  the  phenomena  of  internal  poisoning,  cutaneous  eruptions 
occur  from  arsenic.  The  extensors  of  the  hands  and  feet  are  espe- 
cially affected.  In  some  instances,  said  to  be  not  uncommon  in 
Russia,'^  paralysis  of  the  extremities,  with  muscular  atrophy,  happens. 
Arsenical  paralysis  may  have  mainly  the  symptoms  of  pohomyelitis, 
as  I  have  had  occasion  to  observe.*  In  other  cases  there  are  severe 
darting  pains  in  the  arms  and  legs,  defective  cutaneous  sensibility,  loss 
of  knee-jerk,  and  the  appearances  of  locomotor  ataxia.'"'     The  palsies 


^  Clapton,  Clinical  Society's  Transactions,  vol.  iii. 

^  James  Putnam,  Analysis  of  Twenty-six  Cases,  Bost.  Med.  and  Surg.  Journ. 
March,  1889. 

3  Scolosuboff,  Arch,  de  Phys.,  Sept.  1875. 
*  Phila.  Med.  Times,  March  and  July,  1881. 
'"  Dana,  Brain,  vol.  ix. 


MEDICAL  DIAGNOSIS. 

of  arsenical  poisoning  are  now  generally  thought  to  be  due  to  periph- 
eral neuritis. 

The  inhalation  of  the  fumes  of  zinc  gives  rise  to  a  peculiar  form  of 
poisoning,  characterized  by  a  sense  of  weariness,  by  a  feeling  of  tight- 
ness in  the  chest,  and  by  attacks  of  shivering,  followed  by  heat  of  skin 
and  a  profuse  sweating-stage.  This  irregular  form  of  ague  is  common 
among  brass-founders.^ 

Carbon  disulphide  produces  toxical  effects  of  a  singular  character, 
conspicuous  among  which  are  gastric  disturbances,  inordinate  appe- 
tite, loss  of  muscular  strength,  a  cachectic  condition,  a  feeling  of  icy 
coldness  in  the  lower  limbs,  severe  cramps  in  the  calves  of  the  legs, 
impotence,  and,  in  severe  cases,  amaurosis,  impaired  hearing,  hallu- 
cinations, loss  of  memory,  and  complete  perversion  of  the  intellect.^ 
These  phenomena  are  met  with  among  workers  in  india-rubber. 

Phosphorus  is  often  seen,  particularly  among  those  who  work  in 
lucifer-match  factories,  to  give  rise  to  serious  lesions.  When  the 
poisoning  is  caused  by  inhaling  the  vapor,  it  may  occasion,  as  acute 
phosphorus  poisoning  does,  alteration  of  the  composition  of  the 
blood,  a  hemorrhagic  diathesis,  a  fatty  degeneration  of  several  organs, 
as  well  as  of  the  voluntary  muscles,^  and  peptonuria.  It  also  pro- 
duces chronic  bronchial  catarrh,  but  especially  necrosis  of  the  jaw,  for 
which  the  whole  lower  jaw  has  been  removed.*  The  disease  begins  in 
carious  teeth,  and  may  extend  to  the  cranial  bones.  Osteophytes 
form  freely  in  the  affected  bones.  Phosphorus  taken  internally  in 
doses  that  gradually  exert  a  poisonous  effect  leads  to  chronic  inflam- 
mation and  thickening  of  the  stomach,  colicky  pains,  diarrhoea,  hectic 
fever,  general  emaciation,  falling  out  of  the  hair,  and  to  palsies,  which 
are  generally  the  precursors  of  a  fatal  termination. 

Animal  Poisons. — These  may  give  rise  to  chronic  as  well  as  to 
acute  poisoning.  We  find,  for  instance,  syphilis,  gonorrhoea,  hydro- 
phobia, dissecting  wounds,  snake-bites,  acute  glanders,  and  farcy, — 
all  disorders  exhibiting  the  effect  of  an  animal  virus.  But  we  have 
already  discussed  some  of  these  as  far  as  is  admissible  in  a  work  of 
this  kind ;  and  of  the  others  it  need  only  be  said  that  the  antecedent 
circumstances  generally  place  the  diagnosis  beyond  a  doubt. 


1  Greenhow,  Med. -Chir. 'Transact.,  1862. 

^  Delpech,  Memoires  de  TAcademie  de  Medecine,  1856  ;  and  Heurtaux,  Recueil 
de  la  Societe  Medicale  d' Observation,  1860. 

^  Lancereaux,  L'Union  Medicale,  1863. 

^  Cases  of  Hunt  and  Boker,  Amer.  Journ.  Med.  Sci.,  April,  1865  ;  Wells,  New- 
York  Med.  Journ.,  Jan.  1866  ;  Wegener,  Virchow's  Arcliiv,  Bd.  xl. 


POISONS  AND  PARASITES.  909 

Yet  there  are  a  few  illustrations  of  animal  poisons  and  their  effects 
which  must  be  here,  however  briefly,  mentioned. 

One  of  these  is  the  malignant  pustule  or  anthrax^  a  terrible  mal-^ 
ady,  which  is  the  cause  of  many  deaths  on  the  Continent  of  Europe, 
and  which  is  identical  with  the  charbon  of  animals.  The  disorder  is 
also  prevalent  in  New  Mexico.^  It  is  communicated  to  man  by  direct 
inoculation ;  or  by  means  of  the  skin  or  hair  of  the  diseased  beast,  or 
by  eating  its  flesh ;  or  by  insects  which,  sucking  the  poison  from  the 
sick  animal,  implant  it  in  the  skin  of  man.  The  poison  produces  a 
red  speck,  which  develops  into  a  vesicle,  under  and  around  which  an 
extremely  hard  spot  forms  that  becomes  gangrenous.  The  surround- 
ing skin  inflames,  new  vesicles  or  pustules  spring  up,  and  the  gan- 
grene spreads  rapidly,  the  patient  speedily  sinking ;  or  the  death  of 
the  parts  is  arrested,  and  separation  takes  place  between  the  living 
and  the  gangrenous  textures.  In  some  cases  it  is  attended  with 
extended  cedematous  swelling  and  infiltration  of  the  areolar  tissue 
spreading  from  the  anthrax  pimple.  It  is  remarkable  how  little  local 
pain  attends  the  grave  constitutional  disturbance,  and  the  signs  of  low, 
irritative  fever.  The  disease  is  found  on  the  exposed  portions  of  the 
body,  as  on  the  neck  and  hands.  It  has  been  traced  by  Davaine  to 
the  presence  of  filiform  bacteria,  bacillus  anthracis.  The  blood  swarms 
with  these  bacilli. 

Closely  connected  with  malignant  pustule  is  the  so-called  "  ivool- 
sorter's  diseased  The  wool  from  sheep  is  not  nearly  so  dangerous  as 
the  hair  from  the  goat,  the  alpaca,  and  the  camel.  The  symptoms 
may  be  those  of  malignant  pustule  with  secondary  splenic  fever,  or 
there  often  is  an  utter  absence  of  either  external  or  internal  pustule.^ 
The  manifestations  of  the  disease  are  a  low  fever  with  secondary  ab- 
scesses, pysemic  symptoms,  and  pleuro-pneumonia.  The  complaint 
is  a  dangerous  one ;  when  ending  in  recovery,  convalescence  is  slow. 

Another  disease  transmitted  from  infected  animals,  and  popularly 
known  as  the  "  lumpy  jaw,"  is  the  so-called  actinomycosis  homims, 
described  chiefly  by  Israel^  and  by  Ponfick.*  The  malady  first 
appears  in  the  lower  part  of  the  face,  in  the  shape  of  little 
abscesses  containing  yellowish  granules,  which  consist  of  ray  fungi. 
These  vegetations  are  readily  detected  by  the  microscope.  The  dis- 
ease spreads  to  the  ribs  and  vertebrae,  and  produces  great  destruc- 

'  A.  H.  Smith,  Amer.  Journ.  Med.  Sci.,  April,  1867. 

''  Bell,  Lancet,  June  12,  1880. 

*  Virchow's  Archiv,  Bde.  Ixxxv.,  Ixxviii. 

'  Die  Actinomykose  des  Menschen,  Berlin,  1882. 


910  MEDICAL   DIAGNOSIS. 

tioii  of  tissue ;  it  is  also  found  in  the  liver  and  the  lungs,  in  the 
brain,  in  the  intestines,  and  in  the  skin ;  there  are  the  symptoms  of 
^chronic  pygemia.  The  affection  may  be  mistaken  for  tubercle,  stroma, 
or  malignant  tumor.  Various  forms  of  it,  as  of  the  liver  and  of 
the  lungs,  have  been  already  described .  in  connection  with  those 
organs. 

The  foot  and  mouth  disease  is  an  affection  from  which  especially 
children  suffer  who  have  drunk  the  milk  from  infected  cows.  The 
poison  produces  an  aphthous  stomatitis  with  digestive  disorder,  and 
frequently  also  a  vesicular  eruption  on  the  face  and  on  the  fingers  and 
hands,  which  gradually  dries  into  brownish  scales,  and  at  times  a 
similar  eruption  between  the  toes.  The  disorder  is  not  a  serious  one. 
It  is  due  to  a  micro-organism,  the  streptocytus  of  Schottelius. 

There  is  another  form  of  animal  poisoning  which  may  be  in  this 
connection  briefly  considered, — namely,  mill'-sickness.  It  prevails  m 
some  of  the  new  settlements  of  the  southern  and  southwestern  parts 
of  the  United  States,  and  is  brought  on  by  drinking  the  milk  or  eating 
the  flesh  of  cattle  which  have  been  exposed  to  certain  influences  the 
nature  of  which  is  unknown.  Gastritis  and  enteritis  are  more  or  less 
blended  in  the  early  stage  of  the  disorder,  which  at  a  later  period 
resembles  typhoid  or  typhus  fever.  The  symptoms  are  lassitude, 
nausea  and  vomiting,  with  a  sense  of  burning  at  the  epigastrium,  great 
oppression,  intense  thirst,  fever,  swollen  tongue,  obstinate  constipa- 
tion, fetid  breath,  and  obvious  abdominal  pulsation.  If  at  all, 
recovery  takes  place  tardily,  the  tone  of  the  stomach  being  often 
impaired  for  life. 

There  are  forms  of  animal  poisons  originating  in  alkaloids  generated 

during  decay.     The  poisoning  by  these  jAomaines  from  milk  and  eggs 

and  other  substances  has  already  been  mentioned.     Frecjuently  the 

*  ptomaine  poisoning  resembles  that  of  the  vegetable  alkaloids,  such  as 

of  morphine,  codeine,  and  veratrine. 

Besides  these  forms  of  poisoning,  we  find  morbid  states  occasioned 
by  animal  poisons  which  arise  from  decomposing  bodies  or  excretions, 
or  from  the  crowding  of  many  together,  particularly  of  those  of  un- 
cleanly habits,  or  of  the  wounded.  These  poisons  reach  the  blood  for 
the  most  part  by  the  lungs,  in  the  shape  of  poisonous  exhalations. 
They  are  very  depressing  in  their  action,  may  lead  to  low  fevers,  or  to 
septicaemia,  and  in  the  case  of  the  wounded  to  hospital  gangrene. 
Persistent  nausea,  too,  and  a  lowering  of  vital  energy  are  not  uncom- 
monly observed  in  those  who  breathe  continuously  foul  air  under  the 
circumstances  alluded  to, — as  in  hospitals,  and  in  prisons  in  which 
cleanliness  is  not  enforced  and  due  regard  is  not  paid  to  ventilation. 


POISONS  AND  PARASITES.  911 

In  some  persons  deleterious  emanations  from  tlie  liiiman  body 
give  rise  to  a  form  of  toxaemia,  one  of  the  chief  features  of  whicli  is 
the  marked  anorexia  which  attends  the  great  debihty.^ 

The  exposure  to  animal  effluvia  may  also  excite  violent  diarrhoea, 
or  even  symptoms  like  those  of  cholera,  certainly  like  those  of 
severe  attacks  of  cholera  morbus.  Of  the  occurrence  of  the  former  we 
have  an  illustration  in  the  dissecting-room  diarrhoea,  which  is  usually 
attended  with  very  fetid  discharges,  and  m"ky  be  accompanied  by 
colicky  pains,  by  nausea  and  vomiting,  and  by  headache.  The  same 
kind  of  diarrhoea  also  happens  in  those  who  clean  privies,  or  who  are 
exposed  to  the  emanations  arising  from  sewers  ;  or  dysentery  or  chol- 
eraic attacks  may  follow  the  exposure.  Nay,  as  in  instances  recorded 
by  Becquerel,  the  instant  disengagement  of  large  quantities  of  putrid 
gases,  arising  from  bodies  far  advanced  in  decomposition,  where  coffins 
have  been  opened,  has  caused  sudden  deaths,  or  has  resulted  in  so 
serious  a  state  of  poisoning  as  to  give  rise  to  grave  illnesses,  having 
mostly  a  fatal  termination.^  In  individuals  who,  in  consequence  of 
their  vocation,  are  habitually  brought  in  contact  with  animal  effluvia 
and  inhale  noxious  gases,  besides  the  attacks  of  diarrhoea  referred  to, 
chronic  disturbances  of  the  stomach  and  liver,  with  marked  impair- 
ment of  the  general  health,  may  happen.  Cases  occur,  too,  of  self- 
infection  from  ptomaines  resulting  from  decomposition  of  fecal  matter 
lodged  in  the  caecum,  or  by  perforations  taking  place  from  the  intestine 
into  abscesses  near  by,  into  which  .the  contents  of  the  bowel  find  their 
way. 

PARASITES. 

Parasites  are  organisms  which  become  secondarily  implanted 
within  or  upon  the  body.  Some  parasites  give  rise  to  no  symp- 
toms at  all ;  many  occasion  phenomena  closely  resembling  those  of 
other  irritations.  In  any  case,  the  only  absolutely  convincing  evidence 
of  the  presence  of  a  parasite  is  obtained  by  seeing  it. 

Vegetable  Parasites. — The  chief  vegetable  parasites  have  been 
mentioned  in  connection  with  diseases  of  the  skin ;  the  oidium  albi- 
cans, present  in  thrush,  and  the  sarcinae  ventriculi,  have  also  been 
described.  All  these  vegetable  growths  can  be  detected  only  by  the 
microscope ;  and,  particularly  in  those  involving  the  skin  or  the  hair, 
it  is  of  the  utmost  use  to  employ  lic|uor  potassae,  under  the  action  of 
which  the  structures  become  transparent, 

^  See  Hunt's  case,  described  by  himself,  in  Pennsylvania  Hospital  Reports, 
vol.  i. 

''  Traite  d'Hygiene,  3d  edit.,  p.  218. 


912  MEDICAL  DIAGNOSIS. 

Aspergillous  infection  of  the  lung,  with  haemoptysis  and  cavity-for- 
mation, in  persons  engaged  in  cardmg  hair  obtained  from  rag-pickers, 
has  been  observed  by  Renon/ 

A  similar  fungus  that  penetrates  the  internal  tissues,  the  chionyphe 
Carteri,  gives  rise  to  that  terrible  disease  known  as  podelcoma,  or  the 
fungus  foot  of  India, — a  complaint  found  among  the  natives  of  India 
who  go  about  with  naked  feet.  The  fungus,  introduced  either  through 
a  scratch  or  passing  through  the  pores  of  the  skin,  soon  spreads, 
eating  its  way  into  the  bones  of  the  tarsus  and  metatarsus,  and  into 
the  lower  end  of  the  tibia  and  fibula,  producing  a  breaking  up  and 
absorption  of  the  osseous  tissues.  The  fungous  particles  or  masses 
are  generally  of  deep-black  color,  firm  and  globular,  though  they  may 
be  white  or  pinkish.  The  foot  is  enlarged  about  the  ankle  and  over 
the  instep  ;  and  on  each  side  of  the  ankle-joint,  and  on  the  dorsum  as 
weh  as  on  the  sole  of  the  foot,  are  small,  soft  swellings,  having  poutmg 
openings  that  lead  to  fistulous  canals  communicating  with  the  bones, 
which  they  perforate  in  every  direction.  The  fungous  mass  is  for  the 
most  part  situated  in  the  cavities  in  the  bones,  and  from  the  canals 
passing  to  them  transudes  a  discolored,  glairy,  or  purulent  and  fetid 
fluid.  The  toes  are  distorted,  and  the  muscles  of  the  leg  atrophied ; 
but  the  fungus  does  not  spread  up  the  leg.  The  tendency  of  the 
disease  is  to  cause  death  by  exhaustion ;  the  only  remedy  is  amputa- 
tion.^    The  affection  has  also  been  observed  in  this  country.^ 

A  similar  disease,  leading  to  local  destruction,  is  the  perforating 
ulcer  of  the  foot.  It  is  very  uncommon  in  this  country,  although  I 
have  known  of  cases  ;  in  France  it  is  not  uncommon.  It  is  supposed 
to  be  due  to  defective  vitality  of  the  parts  from  altered  nerve-supply 
and  the  presence  of  pathogenic  micro-organisms.  Local  ansesthesia, 
lowered  temperature,  and  a  tendency  to  profuse  perspiration  exist. 
The  ulcer  leads  down  to  diseased  bone.  It  is  generally  situated  on 
the  first  or  the  last  toe,  over  the  articulation  of  the  metatarsal  bone 
with  the  phalanx. 

The  toes  sometimes  drop  off  from  a  disease  which  constricts  them 
and  enlarges  them  beyond  the  point  of  constriction.     The  affection  is 

^  Monograph,  Vienna,  1896,  Coniptes-Rendus  de  la  Soc.  de  Biol.,  Nov.  1,  1895. 

2  See  Carter,  in  Transact.  Bombay  Med.  and  Phys.  Soc.  ;  and  on  Mycetoma,  or 
the  Fungus  Disease  of  India,  London,  1874. 

"  Kemper,  American  Practitioner,  Sept.  1876.  Cases  reported  by  Adami  and 
Kirkpatrick  in  Montreal  Medical  Journal,  Jan.  1896  ;  by  Hyde  and  Senn,  Journal  of 
Cutaneous  and  Genito-Urinary  Diseases,  Jan.  1896  ;  by  Pope  and  Lamb,  New  York 
Medical  Journal,  vol.  Ixiv.,  1896  ;  by  Wright,  Trans,  of  Apoc.  of  Amer.  Phys.,  1898  : 
and  by  Arwine  and  Lamb,  Amer.  Journ.  Med.  Sci.,  Oct.  1899. 


POISONS  AND   PARASITES.  913 

not  unusual  in  Brazil,  and  seems  to  be  peculiar  to  the  negro.  It  is 
known  as  ainhum} 

Infectious,  multiple  gangrene  of  the  skin  may  be  caused  by  differ- 
ent varieties  of  micro-organisms.  It  has  been  found  due  to  them  in 
tuberculosis  and  in  typhoid  fever. 

Animal  Parasites. — When  speaking  of  the  affections  of  particu- 
lar structures,  some  of  these  intruders  have  been  mentioned, — those 
found  in  the  skin  or  in  the  liver,  for  instance.  It  remains  to  consider 
chiefly  such  of  the  more  important  ones  as  inhabit  the  hollow  viscera, 
certain  solid  organs,  and  the  muscles. 

Intestinal  worms  are  the  most  common  of  all  parasites.  The  gen- 
eral symptoms  induced  by  them  are  those  of  intestinal  irritation  with 
disordered  digestion.  The  appetite  is  capricious ;  the  bowels  are 
irregular,  sometimes  constipated,  sometimes  relaxed ;  the  abdomen  is 
frequently  swollen  and  hard,  and  the  seat  of  uneasiness  or  of  colicky 
pains  ;  the  tongue  is  furred  ;  the  breath  is  fetid  ;  and  there  is  constant 
itching  about  the  nostrils  and  anus.  The  patient,  furthermore,  grits 
his  teeth  during  sleep,  and  is  often  annoyed  by  nightmare.  Nervous 
disturbances  are  also  met  with  ;  they  may  range  from  mere  fretfulness 
to  delirium,  convulsions,  chorea,  epilepsy,  or  insanity.  Strabismus 
and  amaurosis  may  be  also  due  to  worms.^ 

There  are  many  kinds  of  worms  known  to  infest  the  alimentary 
canal  of  man,  and  they  belong  to  the  order  of  nematoda,  or  round 
worms,  or  to  that  of  cestoda,  or  tape-worms. 

The  round  worms  are  parasites  of  an  attenuated  or  cylindrical 
form,  and  present  these  varieties  : 

1.  The  ascaris  lumbricoides^  or  round  ivorm,  bears  a  considerable 
resemblance  to  the  common  earth-worm.  It  inhabits  the  small  intes- 
tine, sometimes  finding  its  way  into  the  stomach,  or  even  into  the 
oesophagus,  or  being  discharged  through  the  abdominal  parietes.^ 
When  it  ascends  to  the  stomach  and  oesophagus  it  causes  sudden 
attacks  of  fever  and  gastric  derangement,  with  nausea  and  vomiting ; 
and  even,  at  times,  marked  delirium.*  The  worms  have  been  known 
to  be  so  numerous  as  to  obstruct  the  intestine. 

2.  The  oxyuris  vermicularis,  thread-worm  or  seat-worm^  is  very 
small,  the  male  being  about  two  lines,  the  female  about  five  lines  in 
length.     The  parasite  is  white,  slender,  and  extremely  active  ;  it  is 

^  Da  Silva  Lima,  Arch,  of  Dermatol.,  Oct.  1880  ;  Duhring,  Amer.  Journ.  Med. 
Sci.,  Jan.  1884. 

2  Hogg,  Brit.  Med.  Journ.,  July,  1888. 

*  Garnier,  L'Union  Medicale,  Oct.  1861. 

*  Schmidt's  Jalirbiicher;  No.  10,  1868. 

57 


914  MEDICAL   DIAGNOSIS. 

found  in  the  anus,  and  causes  intense  itching  of  this  part.  The  an- 
noyance is  sometimes  such  as  to  excite  a  suspicion  of  the  existence  of 
piles.  It  may  creep  into  the  vagina,  giving  rise  there  to  profuse  dis- 
charge ;  or  into  the  urethra.  It  affects  children  frequently,  but  is  not 
uncommon  in  adults. 

3.  The  ascaris  mystax,  a  parasite  which  inhabits  the  cat,  may  also 
infest  the  human  body.  It  is  a  moderate-sized  nematode,  from  two  to 
three  inches  long,  though  the  female  may  reach  about  four  inches. 
Its  head  end  is  spear-shaped. 

4.  The  trichocephalus  dispar^  or  long  thread-ioorm,  is  detected  in 
very  large  numbers  in  the  ileum  near  its  termination,  or  in  the  colon, 
particularly  at  its  head.  It  is  from  an  inch  and  an  half  to  two  inches 
in  length,  and  is  characterized  by  the  hair-like  appearance  of  the  head, 
which  is  generally  buried  in  the  mucous  membrane  of  the  intestine. 
It  is  not  a  common  parasite,  and  it  is  doubtful  whether  its  presence 
gives  rise  to  any  marked  derangement.  It  has  been  found  in  the  typh- 
fevers,  and  in  persons  dying  from  cholera  or  diarrhoea. 

The  tape-worms  are  jointed  entozoa,  of  a  ribbon-like  form.  They 
embrace  the  true  tape-worms,  or  tseniadse,  and  the  bothriocephali. 
Of  the  former  there  are  eight  varieties,  all  of  which  have  been  found 
in  man,  though  only  two — the  solium  and  the  mediocanellata — are  at 
all  common  ;  the  taenia  saginata,  however,  has  spread  over  parts  of 
Western  Europe.^  The  bothriocephalus  latus  is  the  usaal  species  of 
bothriocephalus  met  with  in  the  human  intestine  ;  it,  too,  is  increasing 
greatly  in  Europe,  and,  it  is  said,  in  Texas,  particularly  in  the  western 
portions.^ 

The  to&nia  solium^  or  porh  jtape-worm,  consists  of  an  immense 
number  of  joints  in  connection  with  a  single  head.  It  inhabits  chiefly 
the  small  intestines.  The  researches  of  Kiichenmeister,^  von  Siebold,* 
and  others  have  shown  that  its  eggs  become  developed  into  the  cysti- 
cercus  cellulosce  discerned  in  the  muscles  of  the  pig,  rabbit,  and  other 
animals  whose  flesh  is  used  as  food.  Being  once  introduced  into  the 
alimentary  canal,  they  find  there  a  nidus  in  which  to  undergo  devel- 
opment into  the  tape-worm,  Cysticerci  have  also  been  detected  in 
the  muscles,  the  cellular  tissue,  the  brain,  the  spinal  cord,  the  heart, 
and  the  liver  of  man,  and  are  most  commonly  met  with  in  middle  age 


^  Von  Zehender,  Parasitical  Diseases  of  tlie  Eye,  Bowman  Lectures,  Deutsch. 
Med.  Wochenschrift,  No.  50,  1887. 

^  Colman,  quoted  in  Sajous's  Annual,  vol.  i.,  1890. 

^  See  Manual  of  Animal  and  Vegetable  Parasites,  Syd.  Soc.  transl.,  1857. 

*  Origin  of  Intestinal  Worms,  ibid.,  1857. 


POISONS  AND  PAEA8ITES. 


915 


and  in  the  destitute  ;  they  are  the  most  frequent  parasite  in  the  eye/ 
They  cannot,  as  a  rule,  be  diagnosticated,  except  they  be  in  positions 
in  which  they  can  be  seen  or  felt,  or  the  little  tumors  they  occasion  in 
the  subcutaneous  tissue  be  extirpated  and  examined.     In  the  brain 

their  chief  symptom  is  violent  and 
Fig.  87.  rapidly  increasing   epilepsy.     In   a 

case  reported  by  Lloyd,^  in  which 
cysts  developed  in  the  right  lateral 
ventricle  and  fourth  ventricle,  the 
symptoms  were  severe  and  constant 
headache,  loss  of  memory,  and  a 


Fig. 


Segments  of  tsenia  solium.    Drawn  from  a 
specimen. 


Heads  of  tsenise,  magnified,  except  the  small 
central  figure,  which  represents  the  head  and 
neck  of  tsenia  solium,  natural  size.  The  figure 
to  the  left  is  the  taenia  solium,  that  to  the  right 
the  mediocanellata. 


sensation  as  if  a  ball  were  loose  in  the  head  and  rolled  about  from  the 
front  to  the  back.  There  was  left  hemiparesis  with  ataxia,  exaggerated 
knee-jerks,  involuntary  evacuations  of  the  bowels,  and  failing  vision,  but 
no  epileptic  attacks. 

The  tape-worm  is  nourished  from  its  head,  the  newly  created  flat 
segments  pushing  those  already  formed  before  them,  so  that  the  caudal 


1888. 


^  Berenger-Feraud,   Lemons  de  Clinique  sur  les  Taenias  de  T  Homme,   Paris, 
Transaction  College  of  Physicians,  vol.  xx.  p.  32,  1899. 


916  MEDICAL  DIAGNOSIS. 

extremity  is  the  oldest  portion  of  tlie  animal.  Each  segment  contains 
both  a  male  and  a  female  organ,  the  orifices  of  which  are  joined  at 
the  apex  of  a  lateral  papilla.  In  the  tcenia  solium^  the  papillae  are  ar- 
ranged alternately  at  one  side  and  the  other.  The  size  of  the  seg- 
ments increases  gradually  towards  the  caudal  extremity,  the  largest 
being  three  or  four  lines  in  breadth.  There  may  be  upward  of  eight 
hundred  segments,  and  the  worm  may  measure  above  thirty  feet. 
Upon  the  head,  which  is  about  as  large  as  that  of  a  pin,  is  a  double  circle 
of  hooks  contained  in  sacks  ;  the  slender  neck  exhibits  no  segmentation. 
The  sucking-disks  in  the  tcenia  mediocaneUata  are  larger  than  in  the 
taenia  solium,  but  the  head,  which  is  of  blackish  appearance  and  obtuse, 
has  no  hooks. 

The  tape-worm  most  frequently  seen  in  this  country  is  the  taenia 
mediocaneUata,  or  saginata,  which  is  usually  found  in  beef.  Leidy 
stated,  as  the  result  of  a  large  experience,  that  he  had  rarely  encoun- 
tered the  pork  tape-worm,  tcenia  solium^  as  a  parasite  in  the  human 
intestines  in  this  country.  The  habit  of  eating  raw  or  partially  cooked 
beef  is  the  cause  of  much  of  the  infection  with  tape-worm. 

Taenia  occasions  disordered  digestion,  colic,  cramps,  a  feeling  of 
uneasiness  in  the  abdomen,  irritation  of  the  mouth,  nose,  and  anus, 
anaemia,  headache,  dizziness,  disturbed  sleep,  mental  depression, 
emaciation,  cough,  fainting-fits,  cutaneous  eruptions,  and  various 
cerebro-spinal  affections,  such  as  convulsions  and  epilepsy ;  yet  there 
are  no  absolute  data  for  the  diagnosis  of  the  parasite  except  the  ap- 
pearance of  the  links,  segments,  or  proglottides  in  the  discharges.  In 
order  that  relief  be  permanent,  the  head  must  be  expelled. 

The  bothriocephalus  latus,  tcenia  lata,  or  broad  tape-worm,  differs 
from  the  common  tape-worm  in  having  no  lateral  papillae  alternately 
arranged,  but  a  single  one  at  the  centre  of  each  segment ;  the  seg- 
ments themselves  are  much  broader ;  the  head  is  of  elongated  form, 
has  no  hooks  upon  it,  and  only  a  pair  of  fissures  instead  of  the  four 
mouths  of  the  taenia  solium,  and  we  find  no  traces  of  joints  until 
about  three  inches  from  the  head.  The  parasite  is  of  yellow  or 
grayish-white  color. 

EchinoGOGci,  or  hydatids,  belong  also  to  the  family  of  the  taeniadae. 
They  may  take  up  their  abode  in  almost  any  organ  in  the  body,  es- 
pecially in  the  liver,  and  are  the  immature  brood  of  a  species  of  taenia, 
the  larval  form  of  the  taenia  echinococcus  usually  inhabiting  the  intes- 
tinal tract  of  dogs.  They  consist  at  first  of  a  vesicle  having  at  one 
portion  of  its  wall  a  head,  upon  which  are  six  booklets,  circularly 
arranged ;  but  on  arriving  at  its  resting-place,  the  embryo  loses  its 
booklets,  increases  greatly  in  size,  and  becomes  converted  into  a  vesi- 


POISONS  AND  PARASITES.  917 

cle,  around  which  a  granular  layer  forms  which  afterwards  becomes 
fibrous,  constituting  its  capsule.  The  cysts  develop  in  their  interior 
a  number  of  scolices,  the  larval  form  of  the  taenia  echinococcus.  The 
saline,  non-albuminous  fluid,  contained  in  the  tumor  in  large  quan- 
tity, upon  microscopical  examination  will  usually  show  booklets  as  well 
as  scolices,  thus  absolutely  establishing  the  diagnosis.  A  hydatid  cyst 
may  fail  to  develop  any  scolices,  and  is  then  termed  an  acephalooyst. 
The  whole  animal  is  surrounded  by  an  investing  membrane,  which 
may  burst  and  allow  it  to  escape ;  the  term  hydatid  designates  the 
enveloping  cyst  and  contents.  When  the  echinococci  are  arrested  in 
their  normal  development  and  are  barren,  not  attaining  to  the  pro- 
duction of  scolices,  they  give  rise  to  cysts  with  walls  consisting  of 
distinctly  developed,  concentric  layers.  When  pressed  tightly  by  the 
hand,  they  cause  a  peculiar  gelatinous  trembling  or  purring  sensation. 

The  family  of  the  distomata  is  not  at  all  uncommon  in  man.  A 
species  of  distoma,  measuring  from  eight  to  fourteen  lines  in  length, 
called  the  distoma  hepaticum^  usual  in  the  liver  and  gall-bladder  of 
the  sheep,  has  been  seen  in  the  human  liver  and  gall-duct,  and  also, 
it  is  said,  in  abscesses  of  the  scalp.  Other  species  of  distoma  have 
been  found  in  the  portal  vein,  ureters,  kidneys,  and  bladder,  and  upon 
the  intestinal  mucous  membrane ;  yet  in  the  portal  vein  and  its 
larger  branches — a  common  seat  of  the  distoma — the  parasite  pro- 
duces little  or  no  appreciable  derangement ;  but  when  in  the  intestine 
it  may  give  rise  to  congestion  of  the  membrane,  extravasation  of  blood, 
and  the  symptoms  of  dysentery.  This  has  been  specially  noticed  of 
the  distoma  haematobium,  or  Bilharzia  haematobia,  a  worm  common 
in  Egypt,  and  the  cause  of  the  haematuria  prevalent  at  the  Cape  of 
Good  Hope  and  at  the  Mauritius.  The  entrance  into  the  body  is 
mainly  through  the  urethra  in  persons  bathing. 

Filarice  have  been  met  with  in  the  blood  and  in  the  urine.  The 
Filaria  sanguinis  hominis^  according  to  Bancroft  and  Mason,  gets  into 
the  system  chiefly  through  the  use  of  drinking-water  in  which  the  ova 
of  this  parasite  have  been  deposited  by  mosquitoes,  or  by  entering  the 
skin  of  bathers.  It  gives  rise  to  considerable  pain  in  the  loins,  and 
leads  to  both  bloody  and  chylous  urine,  and,  according  to  Manson,  to 
lymph-scrotum,  the  elephantiasis  of  the  tropics.  Thus  far,  I  believe, 
only  the  filaria  nocturna  has  been  found  in  North  America,  and  ex- 
aminations for  it  must  be  made  in  the  evening.  Saussure^  has  re- 
ported twenty  cases  met  with  in  Charleston,  South  Carolina.  Mastin  ^ 
proves  that  the  filaria  in  the  United  States  may  be  the  cause  of  chylo- 

1  Medical  News,  June,  1890.  "  Medical  Record,  Sept.  1888. 


918  MEDICAL  DIAGNOSIS. 

cele  of  the  tunica  vaginalis  testis.  Henry  ^  reports  a  case  of  cliyluria, 
appearing  after  a  normal  labor  in  a  woman  twenty-nine  years  of  age, 
in  which  he  discovered  filaria  nocturna  in  the  blood.  Dmm  found 
active  embryonic  filaria  in  a  case  in  which  the  symptoms  were  severe 
headache,  fever,  nausea,  pain  in  the  back,  marked  stomach  pain  and 
soreness,  slight  swelling  of  hands  and  feet,  and  puffiness  of  the  face. 
The  urine  was  suppressed  for  forty-eight  hours,  then  chylous  urine 
was  passed,  containing  blood-cells,  albumin,  also  leucocytes,  oil- 
globules,  and  many  embryonic  filarise.^  Osier  has  placed  on  record  a 
case  of  chyluria  persisting  for  thirteen  years  in  which  no  filaria  was 
found.  There  is  thought  to  be  a  non-parasitic  as  well  as  a  parasitic 
chyluria. 

A  worm  called  the  strongylus  gigas  has  been  observed  in  the  kid- 
neys. It  produces  hfematuria,  continuous  pain,  and  an  abdominal 
tumor,^  and  may  lead  to  dropsy  and  death.^ 

The  dochmms  duodenalis  is  a  worm  producing  a  peculiar  antemia 
by  sucking  blood  from  the  walls  of  the  duodenum.  It  has  been  found 
especially  among  brickmakers,  miners,  and  men  working  in  tunnels, 
and  the  disorder  has  been  identified  by  Leichenstern  ^  with  the  so- 
called  Egyptian  chlorosis;  tropical  chlorosis,  and  brickmaker's  anaemia. 
It  has  spread  largely  through  Italian  and  Polish  laborers  employed  in 
building  tunnels,  in  mining,  and  in  brickmaking.  Anchylostomiasis,  as 
the  disease  is  called,  is  characterized  by  marked  anaemia,  by  digestive 
disorder,  abdominal  pains,  and  bleeding  from  the  bowels.  There  is 
a  greater  tendency  to  retinal  hemorrhage  than  in  simple  anaemia.^ 
Sandwith  speaks  of  the  marked  sleepiness  and  dense  stupidity." 

Fly  parasites  may  be  found  m  the  dejections  from  the  bowel 
and  in  the  urine,  producing  local  irritation  of  the  intestine  or  the 
bladder. 

The  parasites  which  chiefly  occupy  the  areolar  tissues  or  the 
muscles  remain  to  be  described.  Of  these  there  are  two  of  special 
importance. 

One  is  the  filaria  medinensis,  dracimcidus,  or  Guinea-u-orm.  This 
is  a  very  slender,  flat,  finely  ringed  worm,  which  introduces  itself  into 

1  Medical  News,  May  2,  1896,  and  Trans.  Assoc.  Amer.  Phys.,  1896. 
'  Transactions  of  the  College  of  Physicians  of  Phila.,  vol.  xx.,  March,  1898. 
^  Magner,  Journ.  de  Med.  de  Bordeaux,  Feb.  1888. 
*  George,  Med.  and  Surg.  Reporter,  Aug.  1888. 

5  Schmidt's  Jahrbiicher,  Sept.  1888  ;  also,  Internationale  klinische  Rundschau, 
Oct.  1888. 

«  Discussion  at  the  Brit.  Gyntecol.  Soc,  Brit.  Med.  Journ.,  June,  1888. 
'  Trans.  Eleventh  Internal.  Medical  Congress,  1894. 


POISONS  AND  PARASITES.  919 

the  subcutaneous  areolar  tissue  :  here  it  grows  rapidly,  and  gives  rise 
to  swelling,  with  more  or  less  inflammation ;  and  sometimes  to  severe 
constitutional  disturbance.  After  a  time  the  swelling  points  and 
breaks,  and  the  worm  may  be  laid  hold  of  and  carefully  twisted 
around  a  little  piece  of  stick  or  a  quill  until  it  is  extracted  entire ;  if 
broken  off,  the  eggs  with  which  it  is  filled,  getting  into  the  wound, 
will  become  the  agents  of  fresh  mischief.  Many  of  these  worms  may 
be  found  in  the  same  patient,  occasioning  great  annoyance  and  dis- 
tress, even  fatal  exhaustion;  but  it  is  stated  that  there  is  often  only 
one  present.  The  number  may  vary  between  this  and  fifty.  Some 
worms  are  twelve,  others  forty  inches  long,  or  even  more.  According 
to  "Busk,  the  parasite  grows  in  the  human  areolar  tissue  at  the  rate  of 
about  an  inch  a  week.  Though  it  is  most  frequently  found  m  the 
lower  extremities,  it  has  been  observed  to  appear  in  the  socket  of  the 
eye,  in  the  mouth,  the  cheeks,  the  ears,  and  under  the  tongue  and  the 
scalp.  It  migrates  rapidly  from  one  part  of  the  body  to  another. 
Where  it  exists,  a  pricking  or  an  itching  heat  is  felt ;  a  vesicle  forms 
when  the  worm  is  about  coming  to  the  surface,  and  this  vesicle  opens, 
leaving  an  angry-looking  ulcer,  in  the  centre  of  which  the  parasite 
shows  itself.  Phlegmonous  spots  may  appear  all  over  the  body  in 
which  specimens  of  dracunculus  are  found.^  The  period  of  incuba- 
tion is  from  eight  to  twelve  months  :  a  year  often  elapses  before  the 
Guinea-worm  makes  itself  manifest  in  the  human  body.^  The  dis- 
order, common  in  Asia  and  in  Africa,  is,  fortunately,  one  with  which 
we  are  unacquainted. 

Trichina  Spiralis. — This  parasite  was  discovered  by  Owen  in 
1835  in  human  muscles  taken  from  the  dissecting-room ;  it  was  sub- 
sequently found  by  Leidy  in  the  animal  which  it  most  infests,  the  pig ; 
but  it  was  not  looked  upon  as  other  than  harmless  until  in  1860  Zenker 
proved  that  trichinae  may  exist  free  in  the  muscles  of  man,  that  they 
are  encapsuled  only  after  some  time,  and  that  they  are  the  cause  of  a 
very  serious  disease. 

The  parasite  is  always  introduced  into  the  body  by  eating  ham, 
pork,  or  sausages  made  from  the  flesh  of  pigs  containing  trichinae. 
It  is  very  probable  that  the  hogs  themselves  obtain  them  from  rats,  in 
which  they  are  common.  It  has  .also  been  stated  that  trichninae  may 
exist  in  beef ;  but  this  is  not  generally  admitted. 

The  trinchina  spiralis  is  the  juvenile  condition  of  a  small  nematode 
worm.     It  becomes  fruitful  only  when  introduced  into  the  intestine. 


^  Woskresensky,  quoted  in  Sajous's  Anmial,  vol.  i.,  1889. 
'^  Aitken's  Practice  of  Medicine,  vol.  i. 


920  MEDICAL  DIAGNOSIS. 

After  being  swallowed,  the  female  trichina  begins  to  throw  off  minute 
embryos,  which  migrate  to  the  muscular  structures.^  When  the 
young  trichina  arrives  in  the  muscles,  it  begins  at  once  to  destroy  the 
muscular  texture.  It  irritates  the  sarcolemraa,  leading  to  its  gradual 
thickening  and  to  an  exudation  that  fixes  the  worm  to  a  particular 
spot.     Thus  is  formed  the  cyst  which   encapsules  the  parasite,  and 

Fig.    89. 


Trichinain  recent  human  muscle,  taken  the  thirteenth  day  of  ilhiess.    (After  Dalton.) 

which  plays  so  important  a  part  in  its  subsequent  destruction.      It 
takes  a  month  or  months  for  the  cyst  to  form  completely. 

After  the  perfect  formation  of  the  cyst,  further  changes  take  place 
in  it ;  particles  of  calcium  and  magnesium  carbonate  are  deposited. 
The  calcareous  mass  extends,  and  gradually  covers  the  whole  para- 
site, while  around  the  prolongations  of  the  cyst  fat-cells  are  deposited. 
The  whole  process  is  very  destructive  to  the  flesh-worm,  and  it  is  thus 
that  the  disorder  is  cured.     But  it  is  apt  to  be  months  before  this  re- 

^  Leuekart.  Uutersuchungen  iiber  Trichina  Spiralis,  Leipsic,  1866. 


POISONS  AND  PARASITES. 


921 


suit  is  accomplished.  Nay,  as  we  know  from  two  cases  recorded  by 
Virchow,  neither  the  encapsuling  nor  the  calcareous  transformation 
kills  the  worms  of  necessity  at  all  speedily ;  for  in  the  one  case  they 
had  remained  alive  for  eight,  in  the  other  for  thirteen  and  a  half  years 
after  the  infection,  and  in  one  instance  mentioned  by  Turner^  they 
were  alive  and  active  after  twenty-six  years. 

The  number  of  trichinae  in  the  muscles  may  be  from  several 
hundreds  to  many  millions.  Now,  in  accordance  with  their  number 
in  the  muscles,  with  the  character  of  the  changes  which  there  take 

Fig.  90. 


Trichina  spiralis.    Magnitied  300  times.    (After  Virchow.) 

place,!  and  with  the  quantity  in  the  intestines,  will  vary  the  extent  of 
constitutional  derangement  and  the  signs  of  local  irritation.  Thus  the 
symptoms  and  the  dangers  of  trichiniasis  are  not  always  the  same. 
When  merely  a  few  thousand  trichinae  occupy  the  muscles,  there  are 
chieflyymuscular  pains  with  stiffness  and  general  debility ;  signs  which 
gradually  ease  as  the  worms  become  encapsuled  and  cretaceous  altera- 
tions occur.  When  the  muscles  are  occupied  by  millions  of  the  flesh- 
worms,  the  local  phenomena  are  much  more  severe ;  there  may  be 
almost  complete  immobility  of  the  whole  body,  the  muscles  of  respira- 
tion and  of  deglutition  are  implicated,  irritative  fever  and  general  ca- 


'  Lancet,  London,  May.  1889. 


922 


MEDICAL  DIAGNOSIS. 


Fig.  91. 


Trichina  capsule  ■svitli  shell-like 
calcareous  deposits.  (After  Leuck- 
art.) 


Fig 


chexia  are  marked,  and  the  patient  is  apt  to  perish  by  gradual  exhaus- 
tion, or  in  consequence  of  the  disordered  respiratory  function,  or  of 
some  pulmonary  complication.     The  presence  of  large  numbers  of 

trichinae  in  the  intestine  produces  diarrhcEa, 
vomiting,  abdominal  pain  and  tenderness  ; 
or  the  worms  may  shortly  after  being  swal- 
lowed give  rise  to  a  kind  of  cholera  mor- 
bus. Should  the  signs  of  the  affection  not 
appear  until  from  twenty-one  to  twenty- 
five  days  after  the  use  of  the  infected  meat, 
and  take  the  form  similar  to  acute  rheu- 
matism of  the  joints,  there  are  not  as  many 
trichinae  present  as  in  the  choleroid  or  the 
typhoid  variety  of  the  malady,  each  of  which  Rupprecht^  has  told  us 
shows  from  five  to  ten  millions. 

Speaking  generally,  we  may  recognize  in  trichiniasis  three  stages  : 
the  first,  lasting  about  a  week,  during  which  the  trichinae  are  being 
generated  in  the  intestines  and  in  which  we  find  only  signs  of  gastro- 
intestinal irritation  ;  the  second,  the  pas- 
sage of  the  brood  into  the  muscular 
textures,  and  the  disturbances  it  there 
occasions ;  the  third,  the  retrogressive 
formation,  which  fairly  sets  in  about  three 
or  four  weeks  after  the  beginning  of  the 
second.  Now,  it  is  the  last  two  stages 
which  yield  the  most  striking  manifes- 
tations of  the  malady  :  loss  of  appetite  ; 
pasty  taste  in  the  mouth ;  nausea  or 
vomiting ;  dry,  somewhat  coated  tongue  ; 
diarrhoea ;  abdominal  pain  and  meteor- 
ism  ;  prostration ;  fever,  with  a  quick 
pulse  and  copious  sweating ;  oedema- 
tous  swelling  of  the  face,  followed  in 
grave  cases  by  almost  general  anasarca ; 
sensitiveness  of  the  skin  and  the  muscles 
to  the  touch,  or  painfulness  when  the 

latter  are  moved,  and  their  contraction  and  difficult  motion  ;  dyspnoea ; 
sleepless  nights  ;  nocturnal  attacks  of  abdominal  neuralgia  ;  and  emaci- 
ation.    There  is  also  decided  leucocytosis. 

The  fever  is  a  marked  symptom.     It  sets  in  early,  owing  to  the 


Eneapsuled  chalky  concretions  in 
muscle,  due  to  dead  trichinae.  Magni- 
fied about  thirty  times.  (After  Leuck- 
art.) 


1  Vierteljahrsschrift  fiir  Ges.  Med.,  Oct.  1880. 


POISONS  AND  PARASITES.  923 

intestinal  irritation,  though  it  is  not  until  the  end  of,  or  after,  the  first 
week,  after  therefore  the  migration  of  the  young  trichinae  has  fairly 
begun,  that  it  is  strikingly  developed.  The  temperature  is  about 
101°,  though  it  may  pass  to  104°  and  105°  ;  yet  it  does  not,  as  a  rule, 
reach  the  high  heat  which  is  observable  in  other  continuous  fevers. 
But  it  is  especially  in  the  attending,  profuse  perspirations,  the  absence 
of  enlargement  of  the  spleen  and  of  an  eruption,  the  swelling  of  the 
face,  the  muscular  symptoms,  and  in  a  very  red  color  of  the  visible 
mucous  membranes,  that  the  points  of  difference  lie  between  the 
febrile  excitement  of  trichiniasis  and  typhoid  fever ^ — a  malady  which, 
on  account  of  the  continuous  fever,  the  prostration,  the  diarrhoea,  and 
the  sudamina,  it  resembles.  In  light  cases  of  trichiniasis  there  may  be 
no  fever,  or  there  may  be  a  fever  more  of  intermittent  or  remittent 
character.  .  The  appearance  of  the  face  may  be  like  that  of  typhus 
fever ;  here,  however,  the  muscular  pains  are  wanting.^ 

The  oedema  marks  the  beginning  of  the  second  stage  of  the  affec- 
tion. It  manifests  itself  first  in  the  eyelids,  about  the  seventh  day  of 
the  disease,  and  is  attended  with  a  catarrhal  state  of  the  conjunctiva, 
with  dilated  pupils,  great  susceptibility  to  light,  diminished  power  of 
accommodation,  and  pain  in  moving  the  eye.  The  swelling  may  ex- 
tend over  the  whole  face,  and  is  sometimes  associated  with  flushing. 
It  is  uninfluenced  either  by  the  sweats  or  by  the  diarrhoea,  but  lessens 
generally  very  much,  or  even  disappears,  after  lasting  eight  or  nine 
days.  But  instead  of  the  oedema  subsiding,  it  may  extend  to  the 
chin,  to  the  arms  and  legs,  and  to  the  back.  It  is  probably  due  to 
pressure  upon  the  arteries,  exerted  by  the  parasites  and  the  exuda- 
tion. The  dropsical  swelling  of  trichiniasis  is  not  associated  with 
albumin  in  the  urine.  Still,  we  find  occasionally  a  slight  amount  of 
albumin,  as  well  as  polyuria,  though  generally  the  quantity  of  urine 
is  diminished.  The  trichinae  may  at  times  be  detected  in  the  passages 
from  the  bowels. 

The  muscular  symptoms  begin  in  the  second  stage,  at  about  the 
tenth  day,  with  pain  and  stiffness  in  the  limbs.  The  muscles  are  ex- 
tremely painful  when  touched  or  moved ;  and  the  patient  lies  in  con- 
sequence as  quietly  as  possible.  The  immobility  is  also  due  partially 
to  the  retracted  state  of  the  muscles  which  occurs,  manifest  for  in- 
stance in  the  semiflexed  position  of  the  extremities,  and  in  the  rigid, 
trismus-like  setting  of  the  jaws.  The  disturbance  of  function  of 
certain  muscles  becomes   particularly  evident.     The  disorder  of  the 

^  See  Clinical  Lectures  on  Acute  Trichiniasis,  by  J.  M.  Da  Costa,  reported  in 
Medical  News  and  Abstract,  March,  1881. 


924  MEDICAL  DIAGNOSIS. 

muscles  of  the  eye  has  been  already  spoken  of;  we  encounter,  besides, 
impaired  hearing,  difficulty  of  deglutition,  and  loss  of  voice,  from  the 
muscles  of  the  ear,  of  the  pharynx,  and  of  the  larynx  being  filled 
with  trichinge.  The  respiratory  muscles  are  commonly  much  affected, 
and  we  find  hurried  and  shallow  breathing.  The  muscles  of  the  heart 
usually,  and  the  unstriped  muscles  of  organic  life  constantly,  escape 
infection  ;  and,  as  the  trichiuEe  wander  to  the  front  of  the  body  rather 
than  to  the  back,  the  muscles  anteriorly  are  more  infested  than  those 
posteriorly.  An  interesting  observation,  which  may  lead  us  to  sus- 
pect the  true  cause  of  the  muscular  pains,  is  the  great  increase  of  the 
eosinophiles  in  the  blood,  to  which  Brown  ^  has  called  attention.  In 
a  case  mentioned  by  Osier  ^  they  reached  sixty-eight  per  cent,  of  the 
total  number  of  leucocytes.  Large  numbers  of  eosinophihc  cells  may 
be  found  in  the  muscles  without  there  being  an  increase  of  these  cells 
in  the  blood.^ 

The  marked  muscular  pain,  the  stiffness,  the  fever,  the  profuse 
sweats,  the  acid  urine,  simulate  the  signs  of  acute  rheumatism;  but 
we  find  in  trichiniasis  diarrhoea,  no  articular  swelling,  and  no  heart- 
complications.  Error  is  more  likely  to  happen  with  reference  to 
acute  muscular  rheumatism.  But  the  signs  of  prostration  and  of 
gastro-intestinal  irritation  are  here  wholly  wanting. 

The  condition  of  the  respiratory  muscles  gives  rise,  as  already 
stated,  to  the  embarrassed  respiration,  but  it  is  not  the  only  cause  of 
the  pulmonary  symjitoms.  Congestion  of  the  lung,  bronchitis,  and 
pleuritis  are  usual.  They  are  not  uncommonly  combined  with  pneu- 
monia, which  appears  suddenly,  selects  the  lower  portion  of  the  left 
lung  by  preference,  occurs  about  the  twenty-sixth  day  of  the  dis- 
ease, and  generally  proves  fatal.  The  sputa  consist  of  dark,  unmixed 
blood ;  and  the  pneumonia  is  thought  to  be  due  to  a  trichinous  em- 
bolism, the  clots  being  derived  from  thrombi,  which  form  in  the 
venous  system.*    Limited  catarrhal  pneumonia  may  be  also  met  mth. 

If  the  patient  escape  a  serious  pulmonary  complication,  if  he  have 
strength  enough  to  withstand  the  weeks  of  irritative  fever  and  exhaus- 
tion, he  enters  at  the  end  of  a  month  or  of  five  or  six  weeks  of  suf- 
fering upon  a  gradual  convalescence.  His  appetite  becomes  insatiable, 
and  he  moves  his  limbs  with  more  and  more  freedom.  But  it  is  a 
long  time  before  he  regains  his  full  muscular  power.     Indeed,  this 


1  Johns  Hopkins  Hospital  Bulletin,  April,  1897,  and  Medical  News,  Jan.  1899. 

^  Practice  of  Medicine,  3d  edit. 

3  Howard,  Phila.  Med.  Journal,  Dec.  2,  1899. 

*  Ru'pprecht,  Trichinen-Krankheit,  1864. 


POISONS  AND  PARASITES.  925 

may  be  always  somewhat  impaired.  In  some  cases  convalescence 
is  greatly  retarded  by  boils,  by  inflammation  of  the  lymphatic  glands, 
and  by  dropsy.  Children  convalesce  more  quickly  than  adults.  They 
suffer,  in  truth,  less  from  the  disease,  and  are  not  very  subject  to  it. 

The  diagnosis  of  the  malady  has  been  made  evident  while  dis- 
cussing the  symptoms.  At  first  the  signs  of  gastro-intestinal  catarrh, 
the  vomiting,  the  slight  fever,  the  perspiration,  the  muscular  feeble- 
ness, are  the  most  significant,  and  these  early  manifestations  might  be 
mistaken  for  irritant  poisoning  ;  we  can  tell  their  meaning  prior  to  the 
marked  development  of  the  phenomena  in  the  muscles  only  by  the 
detection  of  trichinae  in  the  stools.  The  same  may  be  said  of  cholera 
morbus.  Again,  it  must  be  borne  in  mind  that  in  some  cases  of  trichi- 
niasis  the  first  symptoms  of  the  complaint  do  not  happen  for  two  or 
three  weeks  after  the  infected  meat  has  been  eaten  ;  and  that  in  others 
it  runs  a  chronic  course  and  the  whole  disease  is  very  protracted.  The 
so-called  ^''  sausage  poisoning, ^^  not  dependent  on  trichinge,  differs  from 
trichiniasis  in  its  rapid  course  and  in  the  quick  appearance  of  the 
choleraic  symptoms  after  the  spoiled  sausages  have  been  partaken  of. 
In  periarteritis  nodosa  the  severe  muscular  pains  are  associated  with 
thickening  of  the  vessels,  muscular  atrophy,  palsies,  and  great  dis- 
proportion between  the  rapidity  of  the  pulse  and  the  temperature,^ 
and  an  examination  of  the  muscles  will  show  the  absence  of  the 
trichinous  affection.  Indeed,  in  any  instance,  no  matter  what  be  the 
complaint  trichiniasis  may  simulate,  there  is,  though  we  may  suspect 
it  from  the  eosinophilia,  but  one  means  of  determining  the  presence 
of  the  flesh-worms  positively, — to  examine  a  piece  of  muscle.  This 
may  be  efi'ected  by  cutting  down  upon  a  muscle  and  removing  suf- 
ficient of  its  structure  for  a  microscopical  examination,  or  by  using 
Middeldorpff  's  harpoon  or  Duchenne's  or  Hart's  trocar. 

Owing  to  the  oedema,  and  particularly  the  oedema  of  the  eye- 
lids and  face,  the  malady  may  be  confounded  with  Brighfs  disease. 
But  the  absence  of  albumin  and  tube-casts  in  the  urine  distinguishes 
it.  The  physical  signs  separate  the  dyspnoea  it  occasions  from  that 
of  cardiac  disease;  and  the  sweats  and  the  muscular  symptoms  of 
trichiniasis  tell  us  what  we  are  dealing  with. 

1  Schrotter,  Wien.  Med.  Wochenschr.,  No.  15,  1899. 


INDEX. 


A. 


Abdomen,  abscess  in  walls  of .    529,  538 

aneurism    of 519 

auscultation  of 470 

diseases    of 462 

attended  with  pain 512,  520 

simulated  by  hysteria 530 

dropsy    of 604, 610 

enlargement  of,  general ....   463,  610 

partial    617 

examination    of 462 

inflammation  of  muscles  of 527 

distinguished  from  peritonitis  527 

inspection  of 462 

movements  of 463 

palpation  of 464 

percussion   of 465 

pulsation  in 520,  628 

retraction  of  parietes  of 463 

rheumatism  of  walls  of 530 

swelling  of 528 

tumors   of 519,  617 

Abscess,   biliary 589 

embolic 756 

hepatic    586,  601 

lumbar   630 

of  abdominal  walls 529,  538 

distinguished  from  peritonitis  529 
of  brain  distinguished  from  soft- 
ening      209 

from   tumor 211 

metastatic    308,  340,  756 

rupture  of 209 

of  kidney 702 

distinguished  from  cystitis.  .  .   703 

from  pyonephrosis 706 

of  larynx 248 

of  liver 539,  573,  586 

of   mediastinum 434 

of     thoracic     walls     confounded 

with  chronic  pleurisy 362 

perinephritic 703 

peritoneal 627 

peritonsillar    248 

perityphlitic    535 

post-caecal     534 

psoas,    confounded     with     aneu- 
rism        630 

with  appendicitis 538 


Abscess,  pulmonary 327 

distinguished    from    bronchial 

dilatation 327 

from  phthisis 327 

pyaemic 591 

retrolaryngeal   247 

retropharyngeal    115, 247,  458 

subphrenic  589 

tonsillar 248 

tropical 573,  591 

Acanthosis  nigricans 753 

Acarus    889 

Acephaloeysts   917 

Acetone    658,  709 

Achillodynia    774 

Achylia    gastrica 499 

Acidity  of  stomach  as  a  sympton.   476 

Acne   880 

rosacea   880 

Acromegalia    219 

Acroparsesthesia    70 

Actinomycosis,   hominis ..   909 

laryngeal    248 

of  the  liver 588 

of  the  skin 890 

pulmonary   329 

Addison's  disease 751 

confounded  with  acanthosis  ni- 
gricans       753 

with  discoloration  of  lacta- 
tion and  pregnancy 753 

with  disorders  of  liver 753 

with   fever-hues 753 

with  hereditary  hue 753 

with  pernicious  anaemia.  .  .  .   754 

with   phthisis 753 

with  pityriasis  versicolor..   753 
with    Recklinghausen's    dis- 
ease       754 

with  sun-bronzing 753 

with  syphilis 753 

with  vagrants'  disease 753 

Adenoid  vegetations 740 

Adhesions,   pericardial 399,  405 

Adiposa   dolorosa 718 

.Egophony   284 

^sthesiometer    67,  68,  69 

Agraphia    53,  178 

Ague,    dumb 837 

Ainhum    913 

927 


928 


INDEX. 


Air  in  the  blood 764 

Air-passages,  diseases  of 228 

Akaptaphasia    178 

Albumin  in  the  urine 659 

different  kinds  of 698 

diseases  marked  by 680 

tests  for 659 

Albuminose    661, 697 

Albuminuria,  cyclic 684 

following  epilepsy 186 

in  laryngeal  diphtheria 454 

in  malarial  fever 850 

of  old  people 685 

of  uric  acid  and  oxaluria 685 

simple    684 

Albuminuric  retinitis 83,  690 

ulceration  of  bowel 555 

Alcaptonuria 652,  657 

Alcoholism,     acute,     distinguished 

from  apoplexy 173 

from  opium  poisoning 898 

from   sunstroke 181 

chronic    110,903 

Alexia  178,  179 

Algesimeter  470 

Allochiria 69 

Alopecia • 507,  882,  907 

Alvine  discharges 510 

examination  of 510,  511 

Amaurosis   119,  904 

from  gastric  hemorrhage 484 

Amblyopia 54,  84 

Amenorrhcea    495,  739 

Ametropia    84 

Amoeba  coli 510,  558 

dysenterige   558 

Amphoric  voice 284 

sound    268 

Amygdalitis,  follicular 242 

Anaemia    82,  737,  744 

as  a  cause  of  dropsy 716 

cerebral    162,  208 

in  Bright's  disease 689 

essential 740 

from  parasites 738,  740 

idiopathic    740 

of   amoebic   dysentery 558 

pernicious    82,  257,  740 

distinguished    from    Addison's 

disease    754 

spinal    113 

splenic    750 

Anaesthesia 65,  238 

crossed    66 

dolorosa    67 

extended  66 

from  reflex  action 67 

hysterical     • 65 

in  affections  of  nervous  centres.     66 

localized    66 

muscular    69 

of  spinal  origin 66,  100 

one-sided    66 

reflex 67 

tests   for 67 


Anaesthesia,    trigeminal 67 

Analgesia  68 

Anasarca 29,715 

Anchylostomiasis    738,  918 

Anchylostomum    duodenale 738 

Aneurism,   abdominal ....   519,  601,  629 

intracranial   214 

miliary   167,  169 

of   abdominal   aorta   confounded 

with  aortic  pulsation.  .  .  .    630 

with    colic 519,630 

with  disease  of  the  spine.  . .   630 
with  lumbar  and  psoas  ab- 
scess       630 

with  neuralgia 630 

with     non-aneurismal     pul- 
sating tumors 630 

with   rheumatism 630 

of  ascending  aorta 434,  442 

of  descending  aorta 441 

of  heart 441 

of  hepatic  artery 601 

of  innominate  artery 442 

of   pulmonary   artery 442 

of  renal   artery,   multiple 707 

phantom     442 

rupture  of 631 

thoracic    432 

confounded  with  abscess  of  the 

mediastinum   434 

with  chronic  laryngitis  250,  439 
with    intrathoracic    morbid 

growths    433 

with  malformation  of  chest.   438 
with    pulsation    of    pulmo- 
nary artery 437 

eructation  as  a  symptom  of .  . .  478 
tracheal  tugging  a  sign  of ...  .   435 

Angina   Ludovici 456 

pectoris    383 

distinguished     from     brachial 

neuritis    227 

from  cardiac  epilepsy 386 

from  gastralgia 486 

from  intercostal  neuralgia.  386 
from  irritability  of  heart. .  .  386 
from  pain  in  region  of  heart  386 

rheumatic    242 

simple  acute 446 

ulcero-membranous    452 

Animal  parasites 913 

Ankle  clonus 89,  120,  141 

Ano,  fistula  in 314 

Anorexia    148, 475 

Anoxaemia    740 

Anthracosis     604 

Anthrax 909 

Antrum  Highmorianum,  affections 

of     228 

Aorta,  aneurism  of  abdominal.   See 
Aneurism,  ahdominal. 
aneurism   of   thoracic.      See  An- 
eurisni,  thoracic. 

atheroma   of 387 

coarctation  or  constriction  of.  .   436 


INDEX. 


929 


Aorta,  inflammation  of 397,  434 

malposition   of 438 

pulsation   of 397,  628 

valves   of 424 

insufficiency  of 436 

Aortitis    397 

Apepsia,  hysterical 476 

Aphasia    177 

auditory 179 

distinguished  from  apoplexy.  .  .  .    177 

in  pneumonia 180 

in  syphilitic  fever 840 

motor    52,  178 

sensory 178 

visual    179 

Aphonia,  feigned 253 

from  defective  breathing 250 

nervous     250 

of   hysteria 250 

Aphthae 444,  452 

distinguished  from  diphtheria .  .   452 

Apoplexy    167 

attended  with  paralysis 168 

confounded  with  acute  softening 

of  brain 175 

with  asphyxia 175 

with  catalepsy 182 

with  cerebral  hysteria 176 

with  diabetic  coma 175 

with  epilepsy 187 

with  insensibility  from  drink..    173 
with    insensibility    from    nar- 
cotics        173,  897 

with   obstruction   of   the   cere- 
bral  arteries 172 

with  protracted  sleep 175 

with  sudden  extensive  paraly- 
sis        175 

with  sun-stroke 180 

with  syncope 175 

with  ursemic  coma 174 

hemorrhage  the  cause  of 169 

cerebral 170 

seat  of 169 

pulmonary 339 

mistaken  for  acute  pneumonia  339 

serous    169 

spinal    107 

temperature  in 168 

Appendicitis    532,  550 

acute  hemorrhagic 550 

associated   with   typhoid 800 

bacterium  coli  commune  in  ....   533 

chronic   534 

confounded  with  abscess  of  liver  539 
with  acute  intussusception...    537 

with    colic 515,  536 

with  diseases  of  gall-bladder .  .  538 
with  distention  of  cacum....  539 
with  extra-uterine  pregnancy.    537 

with  kidney  disease 537 

with  obstruction  of  bowels .  .  .    537 

with   ovarian   disease 537 

with  pelvic  ha;matoeele 538 

with   pneumonia 539 


Appendicitis   confounded  with   ty- 
phoid fever 536,  803 

with  ulceration  of  ileum 536 

forms  of 531 

perforative     534, 550 

presence  of  pus  in 534 

recurring   540 

Appetite,  exaggerated 476 

loss  of,  as  a  symptom 475 

perverted    507 

Arcus  senilis 79,  414 

Areolar  tissue,  irritation  of 717 

Argyll-Robertson  pupil 81,  138 

Army  itch 889 

Arteries,  atheromatous  changes  in.   721 
cerebral,     obstructions    of,     con- 
founded with  apoplexy 172 

coagulation   in 761 

diseases  of 432,  719 

aphasia  in 179 

embolism   of 761,  762 

inflammation  of  coats  of 719 

mesenteric,  occlusion  of 550 

pulmonary,  aneurism  of 442 

pulsation   of 437 

renal,  multiple  aneurisms  of ...  .    707 

Arteriosclerosis   720 

Arteritis    749,  772 

Arthritis  deformans 778 

distinguished      from      locomotor 

ataxia     779 

from   paralysis   agitans 779 

spurious  779 

Ascaris  lumbricoides 913 

mystax    914 

Ascites    610,  715 

chylous   611 

confounded  with  cancer  of  peri- 
toneum      614 

with  chronic  peritonitis 613 

with  chronic  tympanites 615 

with  distention  of  the  bladder  615 

with  gravid  uterus 615 

with  ovarian  dropsy 612 

with  tubercular  peritonitis...   614 

Asiatic   cholera 563 

Asphyxia  distinguished  from  apo- 
plexy      175 

from  coal  and  charcoal  gases .  .  .    900 

local    888 

Astasia-abasia 76 

Asthenia,   cardiac 392 

Asthma    288 

cardiac   290 

causes  of 289 

diagnosticated  from  croup 289 

from  dyspnoea  of  disease  of  the 

heart     290 

from  enlarged  glands 290 

from  goitre 290 

from  nasal  polypi 232 

from  oedema  and  spasm  of  the 

glottis  289 

from  paralysis  of  vocal  appa- 
ratus     290 


58 


930 


INDEX. 


Asthma  diagnosticated  frora  press- 
ure of  aneurismal  tumor 290 

dyspnoea  in 290 

hay    307 

distinguished      from      chronic 

bronchitis 307 

renal    290,  690 

spasmodic    288 

thymic    290 

Astigmatism 71,  77 

Ataxia 138 

Friedreich's 141,  151 

hereditary    141 

locomotor  138,  141 

See  Locomotor  ataxia. 

progressive    141 

Atheromatous  changes  in  vessels.  .   721 

Athetosis    135,  191 

Atrophy  from  overuse  of  muscles.  .    131 

idiopathic   133 

in  joint-inflammation 131 

of  brain 209 

of  gastric  tubules 499 

of   liver,   acute  yellow 577,  582 

chronic    610 

red 608 

of  optic  nerve 83,  139 

progressive  muscular 129,  134 

unilateral     progressive,     of     the 

face     131 

Aura   epileptica 185 

Auricle,  dilatation  of 437 

Auscultation   271 

of  abdominal  viscera 470 

of    children 286 

of   the  voice 284 


Bacillus  aerogenes  capsulatus ....   407 

coli    communis 510 

fasciculatus 459 

found  in  gastric  carcinoma 500 

of    anthrax 909 

of  cerebro-spinal  fever 815 

of    cholera 564 

of  choleia  morbus 562 

of    diphtheria 447 

of  erysipelas 869 

of  glanders 756 

of  lepra 88G 

of  Malta  fever S32 

of   plague 830,831 

of  pneumonia 298,  344,  359 

of  relapsing  fever 823 

of  scurvy 765 

of  septicsemia ' 758 

of  tetanus 197 

of  tuberculosis 297,  319 

of  typhoid  fever 793,  801 

of  typhus  fever ' 807 

of  yellow  fever 824 

pestis    830 

proteus   flavescens 576 


Bacteria  a  cause  of  disease  of  the 

kidneys     682, 704 

action  upon,  by  leucocytes 735 

in  fecal  discharges 510 

Barbadoes  leg 886 

Barber's  itch 889 

Bedsores   151 

Bell's  palsy 105,  124 

Beriberi    132,  184 

Betabutyric  acid 709 

Bile,    inspissated 580 

in  the  stools 509,  562,  582 

in  the  urine 653 

vomiting   of 481 

Bile-duct,  obstruction  of 579 

Bile-pigment   609 

Bilharzia  hsematobia 667,  917 

Biliary  abscesses 589 

acids   569,  654 

tests  for 654 

calculi     516, 579 

passages,  inflammation  of 579 

coniounded  with  acute  hepa- 
titis     579 

Bilious  attack 490 

pneumonia    346 

relapsing  fever 821 

typhoid  821 

Black    death 830 

Bladder,     disease     of,     associated 

with  paraplegia 118 

distended,    confounded   with    as- 
cites        615 

with  peritonitis 527 

fistula   into 534 

hemorrhage  from 664 

inflammation  of 700 

confounded  with  peritonitis.  .   527 
.  neuralgia  of,  distinguished  from 

acute  inflammation 700 

paralysis    of 115,  646 

spasm  of,  confounded  with  colic  517 

Blindness •. 79,  83,  139 

Blisters   151 

Blood,   air   in 764 

coagulation  of 173 

in   arteries 761 

in  heart 396 

corpuscles    of 734,  735 

crisis     735 

diseases    of 724 

eye  in 82 

filaria  sanguinis  hominis  in ...  .   667 
hsemoglobin        in,        estimation 

of     730, 732 

impoverished 64 

in  Addison's  disease 751 

in  antemia 738 

in  anthrax 909 

in    cerebro-spinal    fever 814 

in  chronic  pleurisy 359 

in    diabetes 709 

in  gastric  cancer 500 

in  gout 776 

in    iiseniophilia 767 


INDEX. 


931 


Blood  in  Hodgkin's  disease 

in   leulvsemia 

in  malarial  fevers 833,  834, 

in  Malta   fever 

n  pernicious  anaemia 

n  pernicious  lover 847, 

n    phthisis 

n  pseudo-leuksemia 

n   purpura 

n  relapsing  fever 

n  scarlet  fever 

in    scurvy 

in  septicsemia 

in  syphilis 

in  trichiniasis 

in  typhoid  fever 

in  typho-malarial  fever 

in  typhus  fever 

in  the  urine 663, 

in  yellow   fever 

microscopic   examination   of .  .  .  . 

pigment    in 764,  851, 

Plasmodia   in 

solutions   for   staining 

specific  gravity  of 

sweating  of 152, 

toxines   in ....  ! 

vomiting    of 482,  495, 

Blood-casts    665, 

Blood-corpuscles    

normal  proportions  of 727, 

rouleaux-formation    of 

shadow   

staining  of 

Blood-extractives 

Blood-plates    

Blood-tests,  in  diabetes 

Blood-vessels,  diseases  of 

Bloody  stools  in  mercurial  poison- 
ing     

in   typhoid   fever 

Body,        extraordinary        swelling 
of     819, 

position  of,  as  a  symptom 

Borborygmi   470,  479, 

Bothriocephalus    latus...    740,914, 
Bowels,  albuminuric  ulceration  of 

atony  of 

cancer  of 

hemorrhage  from 

inflammation    ot 

intussusception    of 537,544, 

invagination    of 

lithsemic  pain  in 

morbid  discharges  from 

obstruction    of 537, 

from  internal  strangulation .  . 

paralysis    of .  . 

stenosis   of. 

strictures    in 

ulceration  of 552, 

Bradycardia    

Brain,  abscess  of 

distinguished  from  tumor .... 
in  cardiac  malformation 


749 

746 
851 
832 
741 
848 
314 
745 
766 
821 
855 
765 
757 
840 
924 
798 
853 
808 
849 
827 
724 
853 
758 
733 
732 
892 
758 
583 
682 
724 
731 
735 
734 
735 
659 
736 
710 
719 

905 
793 

887 
27 
549 
916 
555 
552 
555 
545 
520 
547 
544 
778 
553 
544 
546 
552 
470 
547 
555 
387 
209 
211 
419 


Brain,   abscess   of,   metastatic 

308,  340,  756 

anaemia  of 20S 

and  spinal  cord,  table  of  disor- 
ders   of 153 

aneurism    of 214 

atrophy  of 209 

centi-es  in 50,  52,  54,  55 

concussion  of,  causing  jaundice.    571 

congestion    of 208 

cysts   in 214 

diseases  of 50,  153 

vomiting   in 496 

dropsy  of 161 

emboli    in 172,  762 

hypertrophy  of 218 

inflammation  of 157 

confounded  with  pericarditis.    404 

meningitis  of  base  of 156,  161 

softening    of 207,  210 

acute   158,  175 

chronic   207 

syphilis  of " 122,  840 

thrombosis  of  sinuses  of...    211,759 

tumor   of 158,  210 

distinguished  from  aoscess...    211 
from  chronic  meningitis.  ...    211 

from  softening 210 

gliomatous   214 

seat  of 212 

tuberculous    214 

Brain-power  exhaustion  of 205 

Breathing.     See  Respiration. 
Breath-sound,  metamorphosing. .  .  .    280 

Bright's  disease,  acute 681 

distinguished  from  acute  pain- 
ful  nephritis 683 

from  coma  and  convvilsions .    686 

from   dropsy 685 

from  hsematuria 684 

from   pericarditis. 685 

from   pleurisy 685 

from   pulmonary   oedema.  .  .   685 

from  purulent  urine 683 

from  simple  albvuninuria. .  .   684 
from    suppurative    nephritis  683 

chronic   688 

confounded  with  annemia 689 

with  cancer  of  kidney 692 

with  cardiac  dropsy 691 

with  chronic  bronchitis....    690 
with  chronic  consecutive  ne- 
phritis        693 

with   chronic   rheumatism..    690 

with  cysts  of  kidney 692 

with  diseases  of  the  heart.  .    691 
with    gastro-intcstinal    dis- 
orders      691 

witli  neuralgia 690 

with  renal   iniuloquaey 694 

with    tricliiiiiasis 925 

with  lubercle  of  kidney.  .  .  .    692 

diflVreiit  forms  of 695 

contracting  form  of 697 

jireallmiiiinui'ic   stage   of 663 


932 


INDEX. 


Bright's  disease,  retinitis  in .  .  .    82,  690 
table  of  clinical  differences  in.  .    699 

BroncMal  dilatation 327,  329 

glands,  tuberculization  of 293 

phthisis,       distinguished      from 

whooping-cough    293 

Bronchiolitis  exudativa 308 

Bronchitis,  acute 302,  331,  341 

associated  with  measles 860 

diagnosticated  from   capillary 

bronchitis 304 

from    pneumonia 304 

from    tuberculosis 304,332 

from  whooping-cough 293 

of      large      and      middle-sized 

tubes   302 

physical  signs  of 303 

sputa    in 303 

capillary    248,304 

confounded   with    acute   lobar 

pneumonia   304 

with  acute  miliary  tubercu- 
losis        332 

with  broncho-pneumonia.  .  .   305 
with  catarrhal  pneumonia..   305 

with  phthisis 305 

chronic   306,  319 

confounded  with  Bright's  dis- 
ease      690 

with  nasal  catarrh 307 

with   phthisis 319 

idiopathic,     distinguished     from 

typhoid  fever 804 

of  the  finer  tubes 332 

of    the    large    and    middle-sized 

tubes     302 

plastic    296,307 

sputa  in 308 

putrid ..   308,329 

Bronchophony 284 

Broncho-pneumonia.  .   305,  312,  332,  341 
distinguished  from  tuberculosis.    332 

mistaken  for  collapse 312 

Bronchorrhcea  306 

Bruit  de  glouglou 508 

de   moulin , 407 

Buboes  of  plague 831 

Bulbar    crises 122 

paralysis    127 

asthenic    128 

Bulimia    390,476 

Bulk  of  body 29 

Bullous    diseases 879 


Cachexia  strumipriva ; .  .  .  .   744 

Csecum,  appendix  of,  diseases  of.  .   532 

cancer  of 539 

distention   of 539 

inflammation  of 535 

solitary  ulcer  of 555 

Calcium  oxalate 650,  666 

Calculi,  biliary 516,  579- 


Calculi  of  the  pancreas 

renal   505,  517,  675, 

passage  of 

distinguished  from  malaria . 
from    nephralgia....   676, 

Cancer,  colloid 

of  brain 

of  caecum 

of  colon 

of  gall-bladder 

of  intestine 

of      kidney      confounded      with 

Bright's    disease 

of  larynx 

of  liver 588, 

confounded  with  acute  conges- 
tion    

with  acute  hepatitis 

with  cancer  of  omentum.  .  . 
with  cancer  of  stomach .... 
with  catarrhal  jaundice.  .  .  . 
with  chronic  congestion  .  .  . 
with  disease  of  gall-bladder 

with  enlarged  kidney 

with  fatty  liver 

with  syphilitic  liver 

with  waxy  liver 

of  lungs 324,360, 

confounded  with  chronic  pleu- 
risy    

with  phthisis 

of  lymphatic  glands 

of  lymphatic  glands  lying  by  side 

of  vertebrae 

of   oesophagus 

of  omentum 505,  599, 

of  pancreas 

of    peritoneum 614, 

of   pleura 

of  retro-peritoneal  glands 

of    stomach 497, 

confounded     with     cancer     of 

liver    

with  chronic  gastritis .  .   498, 

with  cirrhosis  of  liver 

with  gastric  ulcer 498, 

situation    of 

supervening  on  ulcer 

of   tongue 

of   tonsils 

primary    

Cancrum  oris 

Capillaries,  diseases  of 

Capillary  pulsation 

Capsules,  suprarenal,  disease  of .  .  . 

Carcinoma,    gastric 

of  peritoneum 614, 

Cardiac  asthenia 

epilepsy    

nerve   storms 

Cardio-pulmonary  sovmds 

Carpopedal  spasm 

Casts  in  plastic  bronchitis.  ...... 

Catalepsy  accompanying  hysteria., 
associated  with  narcolepsy 


620 

679 
678 
677 
678 
627 
214 
539 
624 
598 
628 

692 
256 
593 

596 

596 
599 
599 
596 
595 
597 
599 
595 
597 
595 
364 

364 
324 
750 

625 
460 
614 
620 
627 
361 
615 
502 

599 
501 
609 
501 
502 
505 
445 
458 
593 
444 
722 
38 
754 
498 
627 
392 
386 
387 
317 
200 
308 
182 
176 


INDEX. 


933 


Catalepsy    confounded    with    apo- 
plexy        182 

with  ecstasy 183 

daymare  form  of 183 

feigned    183 

partial    183 

Cataract  78,  708 

Catarrh,   acute 229 

gastric 490,  894 

in  measles 859 

intestinal   520 

nasal     186,  230,  307 

post-nasal    231 

vesical 701 

Catarrhal   fever 785,  830 

distinguished  from  hay-fever...   787 

lung   complications   in 787 

nasal   catarrh  in 230 

sequelae  of 786 

Cavity  in  lungs 318,  327 

Cellulitis,    pelvic 626 

Cerebellum,   diseases   of 143 

gait  in 143,586 

tumor  of 158,  210,  58G 

Cerebral  affections,  forms  of 153 

pain    in,    distinguished    from 
disease  of  frontal  sinus ....    228 

localization    50,  101 

neurasthenia   205,  206,  210 

thermometry   40 

tumors    158,  210,  586 

Cerebritis 157,209 

Cerebro-spinal   fever 812 

blood  in 814 

confounded   with    acute   rheu- 
matism      819 

with  congestive  fever 816 

with  inflammation  of  cord.  .    817 
with  malignant  measles.  ...    818 

with  pneumonia 818 

with  rheumatism  of  cervical 

muscles     819 

with    scarlatina 818 

with  sporadic  cerebro-spinal 

meningitis   817 

with  tetanus 199,  817 

with  tubercular  meningitis.    817 

with  typhoid  fever 816 

with  typhus  fever 819 

with  ursemia 819 

epidemic   814 

lumbar  puncture   in 815 

subsequent  swelling  of  body.  .    819 

urticaria  in 875 

meningitis    163,812,816,817 

sclerosis,    multiple 145 

distinguished  from  general  pa- 
ralysis       217 

typhus    812 

Cestoda 913 

Charbon   909 

Charcot's  disease 145 

Charcot-Leyden  crystals 289,296 

Chest,    alterations    of    form,    size, 
etc.,   of,   in   disease 261 


Chest,    barrel-shaped 309 

contusions  of,  followed  by  pneu- 
monia      344 

dilatation  of,  diseases  presenting  352 

diseases    of 259 

physical  signs  of 285,  357 

girth  of 264 

inspection  of,  in  diagnosis 260 

malformation  of 438 

measurer    264 

mensuration    of 264 

motions  of,  in  diseases  of 261 

palpation  of 265 

percussion    of 266 

retraction   of,   diseases   attended 

with    363 

sounds  of,  on  percussion 267 

tumor   in 360 

Cheyne-Stokes  respiration....    168,384 

Chicken-pox  867 

See  Varicella. 

Chilblains    723 

Chloasma   884 

Chloral    poisoning 174,898,903 

Chlorides  in  the  urine 648 

Chlorosis    30,  38,  739,  744,  760 

blood-changes    in 739,  740 

confounded  with  pernicious  anae- 
mia        744 

Choked  disk 83,  210,  213 

Cholangitis    577 

Cholecystitis    577 

acute     580 

phlegmonous    581 

Cholera     563, 894 

Asiatic,  distinguished  from  chol- 
era morbus 566 

associated  with  ursemia 566 

infantum    561 

morbus    562, 566 

distinguished     from     irritant 

poisoning   563,  894 

from  trichiniasis 925 

nostras   562 

reaction    565 

subnormal  temperature  in 565 

toxine    565 

with  typhoid  symptoms 566 

Cholerine   566 

Chorea    188 

attended    with    salaam    convul- 
sions       193 

caused   by   eye-strain 77,190 

distinguished  from  athetosis.  .  .  .    191 
from  cerebro-spinal  sclerosis.  .    191 

from  convulsive  tremor 191 

from  epilepsy 191 

from  facial  spasm 192 

from  hysteria 194 

from  paralysis  agitans 191 

from  spasms  of  acute  cerebral 

disease    191 

from  tetany 193 

from  writer's  cramp 192 

electrical    190 


934 


INDEX. 


Chorea    habit 190 

Huntington's   190 

hysterical    190 

paralytic 190 

post-hemiplegic ;  .  .  .    192 

post-paralytic    104 

relations  of,  to  rheumatism 189 

Choroid  coat,  inflammation  of 83 

tubercles   of 83 

Chorstek's  symptom 200 

Chyluria     670. 917 

Circulation,    derangements    of,    in 

cardiac  disease 382^  393 

paralysis  from  interference  with .      91 

phenomena  of 58 

portal,  disturbance  of 567 

Cirrhosis   of   liver .  .  ■ 604 

confounded     Avith     cancer     of 

stomach    609 

with  chronic  peritonitis ....    609 
with  inflammation  of  portal 

vein     60S 

distinguished   from   cancer   of 

liver    608 

from  cancer  of  stomach ....    609 

from    hydatids 607 

.   from    other    hepatic    affec- 
tions       607 

from  red  atrophy 608 

from  simple  induration....    608 
from  syphilitic  hepatitis .  .  .    608 

from  malarial  infection 607 

hypertrophic    606 

of    children 606 

of  lung  confounded  with  chronic 

pleurisy    365 

Clergyman's   sore  throat 457 

Clots,  fibrinous,  in  the  heart 396 

Club-foot    133 

Coagula,  fibrinous 296 

Coffee-ground  vomit 483,  499 

Coldness,   sensation  of 415 

Colic  as  a  symptom 512 

bilious     513, 536 

confounded  with   abdominal   an- 
eurism        519,  631 

with  abdominal  neuralgia.  ...   518 

with  abdominal  tumors 519 

with  angioneurotic  oedema.  .  .    519 

with  appendicitis 515,  536 

with  enteritis 519 

with    gall-stones 515 

with   gastralgia 514 

with   hepatic   neuralgia 516 

with    nephralgia 516 

with  neuralgia  of  dorsal  and 

lumbar    nerves 518 

with  perforation  of  the  intes- 
tine       515 

with  peritonitis 519,  531 

with  spasm  of  the  bladder.  ...    517 

with  spinal  disease 519 

with  strangulated  hernia 515 

with  uterine  colic 518 

copper     513 


Colic,    flatulent 

from  disease  of  the  bowel. 

lead   

malarial   

metallic    


nervous     

renal  536,  676, 

simple   

spasmodic    

uterine    

Colitis,   croupous 

entero-    

ulcerative     

Collapse,  delirium  in 

in  acute  poisoning 

in  appendicitis 

in    cholera 565, 

in  relapsing  fever 

in  yellow  fever 

of    the    lung 311, 

confounded  with  chronic  pleu- 
risy    

Colon,   artificial 

dilatation   of 548, 

disease  of,  associated  with  heart 
disease    

malignant   disease   of 

percussion    of 

solitary  ulcer  of 

Color-blindness   .'  . 

Coma    62,  606, 

diabetic 63,  175, 

from  narcotic  poisoning.  .63,  174, 

in  typhoid 

of    apoplexy 63, 

of  Bright's  disease 63, 

ursemic   63,  174,  686, 

Coma-vigil    

Comedo     

Comma-bacillus  of  Koch 

Concretion,    intra-hepatie 

Congestion  of  brain  discriminated 
from  softening 

of  features,  as  a  symptom 

passive    

pulmonary    

Congestive  fever 

See  Pernicious  fever. 

Conjunctiva,  tuberculosis  of 

Conjunctivitis  from  litliEcmia 

Consciousness,  derangement  of .  .  .  . 

diseases  marked  by  sudden  loss  of 
Constipation  as  a  symptom 

causing  chlorosis 

from   mechanical    changes 

habitual   550, 

ulcers    from 

Consumption.      See  Phthisis. 

galloping    331. 

Continued  fever,  simple 

Contractility,  electro-muscular    95, 

Contraction,  front  tap,  of  leg 

Contracture    120, 

CouAiilsions   

See  also  Spasms. 


513 
514 
513 
513 
513 
513 
707 
512 
512 
518 
336 
562 
555 
61 
894 
535 
567 
821 
824 
366 

366 
469 

627 

555 
624 
469 
555 
84 
686 
708 
897 
796 
173 
686 
897 
808 
891 
564 
839 

208 
30 
483 
339 
846 

79 
778 

62 
167 
540 
739 
552 
739 
552 

334 

784 
146 
88 
151 
149 


INDEX. 


935 


Convulsions,   diseases    marked    by  184 

distinguished  from  epilepsy 187 

epileptic   121,  130 

from  cerebral  disorder 186 

from  irritant  poisoning 893 

from  purulent  otitis 187 

from  syphilitic  disease 187 

hysterical 118,  130 

in   apoplexy 167 

in  Bright's  disease 686 

in  scarlet  fever 855 

in   typhoid 796 

of  eccentric  origin. 186 

salaam    193 

unilateral 174 

urfemic   687 

Convulsive  seizures,  limited 187 

tic    192 

Cord.     See  Spinal  cord. 

Corpuscles,   blood- 724 

Coryza 229 

distinguished  from  nasal  hydror- 

rhoea   230 

Cough   291 

dry  and  moist 292 

from  nasal  affections 307 

in  laryngeal  affections 234,  292 

in    phthisis 313 

whooping-    248,  292 

Countenance,    expression   of,    as   a 

symptom    29 

Crackling  in  tubercle  of  lungs  282,  326 

Cramp  of  stomach 484 

Avriter's 192 

Cramps 150 

caused  by  various  occupations.  .    192 

Cranial   reflexes 87 

Craniotabes   782 

Crepitation    282,  341 

Crises,  blood 735 

bulbar 122 

gastric    496 

laryngeal    140 

Croup    243, 289 

catarrhr.l    243 

false    243,  246. 

membranous,  or  true 245,  454 

diseases   confounded   with ....    246 
distinguished  from  abscess  of 

larynx 248 

from  acute  laryngitis 246 

from    diphtheria 249,  454 

from  false  croup 246 

from  oedema  of  the  larynx.  .    247 
from    .  retrolaryngeal       ab- 
scesses      247 

from     retropharyngeal     ab- 
scesses      247 

from  scarlet  fever 855 

from     secondary     laryngitis 

of  the  exanthemata 246 

non-diphtheritic  membranous.  .  .    249 

spasm  of  glottis  in 244 

spasmodic    244 

Crural  neuritis,  general 226 


Crus  cerebri,  lesions  of 110 

Crusta   lactea 877 

Crystals,   Charcot-Leyden 289,  296 

Curschmann's  sign 289 

Cyanosis     30, 338 

Cysticercus    cellulosse 914 

Cystine     676 

Cystitis,   acute 700 

confounded    with    abscess    of 

kidney    702 

with  acute  painful  nephritis  701 

with    metritis 701 

with  neuralgia  of  bladder.  .   701 

with  peritonitis 527 

chronic   701 

Cysts  of  brain 214 

of  kidneys 692,  706 

confounded  with  hydronephro- 
sis      706 

of  nose 232 

of    pancreas 620 

of  vocal  cords 257 

ovarian     538, 612 

fluid    of 613 

parovarian  627 


Day-blindness    84 

Daymare 183 

Dead  flngers 722 

Deafness     85,  86,  231,  452 

Debility  confounded  with  typhoid 

fever    802 

Deep  reflexes 87 

Delirium    60,  155 

confounded    with    delirium    tre- 
mens       165 

fierce 60 

hysterical   ■.  .      62 

in  chorea 189 

in  diseases  of  stomach 61 

in   typhoid 795 

mistaken  for  insanity 61 

of  cerebral  rheumatism 771 

of  inanition 61 

of    pneumonia 60,  334 

prominent  as  a  symptom,  acute 

affections  with 155 

quiet   60 

simulated 61 

tremens    164, 334 

confounded  with  acute  mania.    167 

with  acute  meningitis 165 

urtemic    60, 687 

Dementia  paralytica 215 

senile 217 

Dengue    828 

distinguished   from   influenza...    830 

from  malarial   fever 830 

from  rheumatism  or  gout.  .  .  .    830 

from  scarlet  fever 830,  858 

from   yellow   fever 830 


936 


INDEX. 


Dermatitis    herpetiformis 881 

medicamentosa    884 

Dermatophytes.      See   Tinea. 

Deutero-albumoses     746 

Diabetes    655,  707,711 

coma  in 175,  708 

distinguished  from  carbon  mon- 
oxide  poisoning 655 

from    chronic    polyuria 711 

from   glycosuria 711 

fatty  diarrhoea  in 561 

from  pancreatic  calculi 620 

insipidus    711 

intermitting 711 

phosphatic  647 

retinitis    in 82 

test    for 710 

with  coexisting  albuminuria.  ...   711 

Diacetic    acid 658 

Diacetone 709 

Diagnosis  by  exclusion 22 

differential 22 

methods  of  arriving  at 20 

ophthalmoscope   in 82 

physical    260 

sources  of  error  in 23 

Diaphragm,  fatty  degeneration  of.   291 

hernia    of 356 

paralysis    of 290 

phenomenon  261 

rheumatism  of 291 

Diarrhoea   553,  558 

acute     553 

bilious    553 

choleraic    563 

chronic   554 

fatty   560 

in  pulmonary  consumption 314 

in  typhoid  fever 792 

intermittent    556 

membranous    556 

of  dissecting-room 911 

of    soldiers. .    • 554 

strumous,    of    children 555 

tubercular    554 

Diathesis,  rheumatic 241 

Digestion  as  a  symptom 48 

disorders  of,  in  liver  disease.  .  .  .    567 

Dilatation,    bronchial,    confounded 

with  phthisis 325,  329 

with  pulmonary  abscess. .  .  .    327 
with  pulmonary  gangrene.  .    328 

of  colon 548,627 

of    heart 412 

confounded  with  fatty  degen- 
eration      414 

Avith  pericardial  effusion.  .  .   416 

of   oesophagus 460 

of    stomach 505 

Diphtheria     447 

bacillus    of 447 

confounded  with  aphthae 452 

with  membranous  croup 454 

with  erysipelas  of  the  fauces.   453 
with  sangrene  of  the  mouth .  .   452 


Diphtheria  confounded  with  phar- 
yngitis and  tonsillitis 451 

with    scarlatina 454 

with    thrush 452 

with  ulcerative  stomatitis ....   452 
with    ulcero-membranous    an- 
gina       452 

crmipous    449 

faucial    229 

intercurrent    455 

laryngeal   249,  454 

confounded  with  scarlet  fever  857 

nasal     229, 455 

paralysis    in 121,  142,  450 

sequelae    of 450 

Diplegia    90 

Diplococcus   exanthematicus 807 

in   mumps 455 

intracellularis   815,  817 

pneumoniae 344 

Diplopia  80 

Discharges,  alvine,  as  a  symptom.    509 

Displacements  of  heart 352,  431 

Distoma   haematobium 917 

hepaticum    917 

Dittrich    plugs 308 

Diuresis,   chronic 711 

distinguished  from  hydronephro- 
sis    712 

in  hysterical  women 712 

Dochmius    duodenalis 918 

Dracuneulus    918 

Drink,  insensibility  from 173 

Dropsy    715 

abdominal    603,  610 

cardiac    382,716 

causes  of 716 

dependent  upon  a  tumor 716 

diseases  marked  by 681 

from  anaemia 716 

from  malarial  poisoning 716 

from  scarlet  fever 856 

general    716 

from  irritation  of  areolar  tis- 
sue         717 

from  peripheral  multiple  neu- 
ritis         717 

hepatic   717 

in  Bright's  disease 685,  691 

in  disease  of  liver 603 

internal    716 

of    brain 161,217 

ovarian   612 

pericardial     404 

confounded  with  cardiac  dila- 
tation      416 

peritoneal    611 

renal   716 

Drunkards,   gastritis    of    492 

Duct,    cystic,    obstruction    of,    by 

stones   598 

Duhring's    disease 881 

Duodenum,  catarrh  of 522 

vilcer   of 497 

Dynamometer    94 


INDEX. 


937 


Dj'^sentery    556 

acute     556 

amoebic     558 

catarrhal    558 

chronic   559 

confounded  with  piles 558 

with   proctitis 558 

diphtheritic    558 

distinguished   from  diarrhoea...  558 

epidemic     557 

tropical    510 

Dyspepsia  as  a  symptom  488,  492,  551 

atonic 489 

nervous    488 

Avith  aortic  pulsation 628 

Dysphagia    247, 461 

Dyspnoea    287,  439 

caused  by  aneurismal  tumor  290,  439 

by  goitre 290 

diseases   presenting 353 

from  disease  of  the  diaphragm.  .  290 

from  enlarged  glands  of  neck.  .  .  290 

in  asthma 291 

in   plastic   bronchitis 307 

laryngeal    234 

Dystrophy,  progressive  muscular. .  133 

facio-scapulo-humeral    133 

hereditary    133 

idiopathic     133 

infantile 133 

juvenile    133 

pseudo-hypertrophic    133 

scapulo-humeral    133 


Ear,  disease  of 158 

causing  abscess  of  brain 209 

Ecchymoses    571 

Echinococci    600,  602,  916 

Ecstasy     183 

distinguished  from  catalepsy..  .  .    183 

Ecthyma     882 

Eczema     151, 877 

distinguished      from      pityriasis 

rubra    878 

from  scabies 879 

from   seborrhoea. 878 

impetiginodes    877 

papular    876 

rubrum     878 

squamosum    878,  883 

Effusions,  pericardial 362,  400,  416 

diagnostic  sign  of 401 

peritoneal     523 

pleuritic. .    310,  312,  323,  349,  358,  589 
distinguished  from  hydatids..   601 

Ehrlich-Biondi  stain 734 

Electricity  in  paralysis 94 

faradaic    94,  96 

galvanic    94, 96 

in  examination  of  stomach 471 

static  or  Franklinic 97 


Electro-muscular  contractility.    95,  123 

sensibility 97 

Elephantiasis   of  the  Arabs 886 

of  the  Greeks 885 

Emaciation  as  a  sjonptom 29 

Embarras    gastrique 490 

Embolism     397,  759,  761 

abscess    from 591 

cerebral     172,  762 

with  hysterical  symptoms.  .  .  .    197 

diagnosis    of 763 

fat   764 

from   accumulations   of  pigment 

in  the  blood 764 

from  acute  endarteritis 764 

of  arteries  of  the  extremities.  .  .    762 

of  cerebral  arteries 762 

of   pulmonary   artery 761 

of   renal   artery 762 

of  vessels  of  liver 762 

splenic    762 

Embryocardia    387 

Emphysema     309,  360 

coexisting  with   tubercle 320 

compensatory    311 

distinguished    from    aneurismal 

tumor    310 

from   chronic   pleurisy 360 

from    pleuritic    effusions 310 

from    pneumothorax 310 

interlobular     311 

Emprosthotonos    198 

Empyema,    pulsating,    confounded 

with    aneurism 436 

Encephalitis 157 

acute  focal 157,  158 

acute  hemorrhagic 158 

diffuse 157 

Endarteritis    719,  764 

gouty    777 

obliterative    721 

Endocarditis,  acute 394 

confounded  with  pericarditis.   402 

associated  with  chorea 189 

diabetic    708 

ulcerative 398,756 

associated  with  pneumonia.  .  .    342 
head-symptoms  of,  confounded 

with  acute  meningitis .  .    160 
with  typhoid  fever..    399,804 
Engorgements,    pulmonary,    in    fe- 
vers      '. 338 

Enlargement  of  body 219 

renal   602 

Enteralgia    514 

Enteritis,   acute 520 

confounded   with   colic 519 

with  peritonitis 526 

with  typhoid  fever 521,803 

croupous  or  diphtheritic 522 

membranous    556 

muco-    521, 553 

Enteroptosis    463,  507 

Eosinophiles    734,  746,  924 

Epigastrium,  pain  and  soreness  in  489 


938 


INDEX. 


Epigastrium,  sensitiveness    of  470, 491 

tumors    of 619 

Epiglottis,  disease  of .  . 238,  242 

Epilepsy 184,  191 

abortive    185,  188 

associated  with  vertigo 185 

aura  preceding 185 

cardiac 386 

consecutive  to  scarlet  fever 856 

distinguished  from  apoplexy.  .  .  .  187 

from  chorea 191 

from  convulsions 187 

from  hysteria 194 

from  strychnine  poisoning.  .  .  .  902 

eccentric  186 

feigned 188 

idiopathic 187 

Jacksonian 187 

masked   187 

nocturnal   185 

post-hemiplegic   186 

sequelae  of 185 

syphilitic    187 

Epiphytes    888 

Epistaxis   300,  786,  797 

Epstein's    stomach    test 469 

Eructation  as  a  symptom 477 

Eruption  in  typhoid 797 

of    smallpox 864 

produced  by  drugs 858 

Erysipelas    230,  453,  868 

associated  with  nasal  catarrh .  .  .  230 

with  pharyngeal  fever 870 

distinguished    from    angeio-iieu- 

rotic   oedema 870 

from  confluent  smallpox 870 

from  erythema 869 

from   exanthematous   fevers .  .  869 

from  mumps 870 

from    scarlatina 869 

from    scleroderma 888 

in  aortitis 398 

migrans    f 870 

of   the    fauces   confounded   with 

diphtheria    453 

phlegmonous   868 

Erythema     151,  396,  869,  874,  880 

desquamative    874 

distinguished  from  erysipelas .  .  .  869 

neurotic  vesicular 879 

Erythromelalgia  723 

Ether  narcosis 684 

Examination  of  patients,  methods 

of  25 

Exanthematous    fevers 853,  869 

Excitation  of  inuscles,   direct  and 

indirect    94 

Exhalations,    poisonous 910 

Exophthalmic  goitre..  .    32,  78,  389,  438 

Exposure  to  cold 221 

Eye,  abnormal  changes  in  fundus  of  81 

abnormalities  of,  external 78 

of  pupils 81 

appearance  of,  in  disease 77 

conjugate  lateral  deviation  of. .  .  79 


Eye,   derangements   of   mechanism 

of    77, 78 

embolism  of 82 

hyperaemia  of 82 

in  hay  fever 79 

lithsemic  disorder  of 778 

paralysis  of  accommodation  of  81,  84 

paresis  of 84 

ptosis  of 80 

reflex  neuroses  of 84 

refraction,  errors  of 778 

sixth  nerve  of,  afl'ections  of 80 

subjective    visual    derangements 

of  83 

third  nerve  of,  affections  of 80 

Eyeball,  protrusion  of 78,  390 

Eyelids,  drooping  of 140 

Eye-strain    77,  83,  190,  778 

as  a  cause  of  chorea. .......    77,  190 

of  epilepsy 77 

of  gastric  derangements 77 

of  hysteria 77 

of  melancholia 77 

Eye-symptoms      in      cerebro-spinal 

sclerosis   146 

in  meningitis 160 

in  paralysis 119 


Face,  moon-shaped 219 

spasm  of 192,  222 

unilateral  progressive  atrophy  of  131 

Facial   palsy 124,  172 

double 125 

Faeces,  accumulation  of 618 

impacted,  simulating  gall-stones  516 

vomiting   of 481 

Faradaic    excitability 96 

Farcy,  acute,  confounded  with  py- 

£emia 756 

Fat  in  intestinal  discharges 560 

in    urine 560,  670 

necrosis    619 

Fatty  degeneration  of  heart..    385,414 

confounded   with    chills 415 

with    dilatation 414 

Avith   her.rt   starvation 415 

of  pancreas 619 

of  tissues  in  poisoning 895 

liver    592,  593 

Fauces,  diseases  of 445 

erysipelas  of 453 

inflammation  of 445 

ulcers   of,   syphilitic 457 

Favus   889 

Fecal    discharges 509 

examination  of 510,  511 

vomiting     481 

Feet,  blueness  and  coldness  of 151 

Feigned   aphonia 253 

epilepsy    188 

hysteria    197 

rheumatism 775 


INDEX. 


939 


Feigned    sciatica 225 

Fever,  bilious  typlioid 821 

breakbone,  or  dengue 828 

catarrhal    785 

cerebro-spinal    812 

Chickahominy 852 

congestive    846 

enteric    789 

erysipelatous 870 

from      contaminated      drinking- 
water    803 

gastro-enteric    847 

glandular  833 

hectic    838 

hemorrhagic   malarial 849 

hepatic   579,  839 

icterode    pernicious 849 

infantile   remittent 846 

in    phthisis 314 

.  intermittent    836 

malarial   833 

malario-typhoid    853 

Malta    831 

measles     858 

miliary   860 

mountain   806 

nervous     795 

pernicious    846 

pharyngeal 870 

puerperal  malarial    840 

relapsing    819 

remittent    841 

scarlet 853 

simple  continued 784 

spotted   808 

syphilitic    839 

thermic 785 

typhoid     789 

typho-malarial    .  .  . 852 

typhus    807 

urethral    839 

yellow   823 

Fevers 783 

classification   of 784 

continued  784 

eruptive  or  exanthema tous .   853,869 

periodical     833 

type  of 784 

Fibrin,  clots  of,  in  the  heart 396 

network  of,  in  blood 735 

Fibroma,  nasal 231 

Fifth  nerve,  painful  anaesthesia  of.  222 

Filaria    medinensis 918 

sanguinis  hominis.    184,667,671,917 

Fingers,   dead 722 

Fistula,   gastro-pulmonary 49;}- 

Flatulency  as  a  symptom 477 

Fluoroscope 262 

Flushing  in  myelitis 115 

Fly   parasites 918 

Foot  clonus 146 

drop 110 

perforating  ulcer  of .  .  .    140,  152,  912 

Foot-and-mouth  disease 910 

Foreign  body  in  bronchial  tube. .  .  .  327 


Foreign  body  in  windpipe 248 

Fraenkel's   symptom 139 

Frtenum  linguae,  ulceration  of 293 

Fremitus,  bronchial 285 

cavernous 285 

friction   266 

l^leural      285 

rhonchal 266 

vocal   266,  284 

absence  of 285 

Friction,  pericardial 380 

pleural    283,  403 

pleuro-pericardial 403 

Friedreich  s   ataxia 141,146,151 

Frontal  sinus,  diseases  of 228 

neuralgia   in 228 

Fungi    295,  459 

poisonous    897 

yeast 480,  510 

Fungus  foot  of  India 912 


G. 


Gait  as  a  symptom 28 

in  cerebro-spinal  sclerosis..  ..."..    145 

in  diseases  of  cerebellum 143 

in  general  paralysis 215 

in  hysterical  hemiplegia 119 

in  locomotor  ataxia 138,  139 

waddling 133 

Gall-bladder,  cancer  of 598 

diseases  of 538,  588 

confounded  with  appendicitis.   538 

with  cancer  of  liver 597 

distention   of 598,  601 

distinguished   from   hydatids   of 

liver    601 

inflammation    of 516,  577 

tumor  of,  in  cholecystitis 581 

Gall-ducts,   inflammation  of..    516,577 

occlusion  of 578 

Gall-stones  'I 506,  515,  598 

associated  with  gastralgia 487 

impacted,  confounded  with   can- 
cer of  the  liver 598 

passage  of 515,  598 

confounded  with  catarrhal  ic- 
terus       579 

with    colic 515 

with  faecal  accumulations..   516 

with  intermittent  fever ....    839 

simulated  by  movable  kidney.   623 

Gallop  rhythm 387 

Galvanic  excitability 96' 

Ganglia,  central  gray,  lesions  of .  .  .    102 

Gangrene,  diabetic 708 

of  ergot  poisoning.  .  .- 904 

of  moutli 444 

pulmonary 295,  308,  328 

senile 723 

symmetrical   722 

Gastralgia   485,  496 

confounded   with    colic 514 

Gastric    cancer 497 


940 


INDEX. 


Gastric  catarrh,   chronic 491 

crises    140, 496 

irritation     404 

juice,  acidity  of 474 

examination    of 472 

motormeter    471 

tubules,  atrophy  of 492,  499 

ulcer    470, 493 

perforating    496 

Gastritis,   acute 489 

from  poisoning 489,  894 

chronic   491 

distinguished  from  gastric  can- 
cer    501 

from   gastric   ulcer 501 

from  hepatic  congestion. .  .  .    585 

from   peritonitis 525 

membranous    490 

of  young  children 491 

phlegmonous   490 

Gastrodiaphane    471 

Gastrodynia     485 

Gastrograph    471 

Gastromalacia 491 

Gastroptosis    507,  739 

Gastroscope    471 

Gastroxynsis   477 

German  measles 861 

Gigantism 219 

Gingival    line 314 

Girdle  pain 115,  146 

sense   139 

Gland,  thymus 290 

thyroid   219, 390, 438 

Glanders    231,  756 

Glands,  lymphatic,  cancer  of 625 

sarcoma  of 750 

swelling  of,  in  dengue 829 

in    plague 831 

of  axilla,  enlarged 434 

of  neck,  enlarged.  .   241,  250,  290,  434 

retroperitoneal,  cancer  of 615 

retropharyngeal    458 

scrofulous    556,  750 

tuberculous    750 

Gland-secretions,   altered 891 

Glandular  fever 833 

Glenard's    disease 507 

Globulin 662 

Glossitis,    acute 445 

Glossoplegia 106 

Glottis,  (Edema  of 290 

spasm  of 244,  290 

Glycosuria  655,  707 

Glycuronic  acid 658 

Goitre  78,  290,  438 

exophthalmic    78,  389,  438 

Gonocoocus 230 

Gonorrhceal  infection  of  nose 230 

rheumatism  770 

Gout    397,411,775 

associated  with  lithsemia 777 

blood  examination  in 776 

distinguished  from  dengue 830 

from  rheumatism 776 


Gout,    rheumatic 778 

Gram's  tests  for  micro-organisms.   299 

Gravel    517-,  644 

Graves's  disease 389,  390 

Guinea-worm  918 

Gummata 132 

Gums,  red  line  of 314 

swollen  443 

Gyromele   471 


H. 


Habit-chorea   . 190 

Habit-spasm 190 

Htematemesis    301,  482,  793 

alcoholic  605 

Hsematoblasts   741 

Hsematocele,   pelvic ,  .    538 

retrouterine   626 

Hsematokrite   727 

Hsematoma 171 

Hsematoporphyrin    635 

Hsematoscope    730 

Hsematuria    665 

confounded  with  acute  Bright's 

disease 684 

intermittent    666 

malarial   667 

neurotic    666 

parasitic     667 

renal  tubal 665,  667 

diagnostic  sign  of 666 

vesical 668 

Hsemidrosis   891 

Hsemocytometer,  forms  of 726 

Haemoglobin    666,  730,  740 

apparatuses  for  estimating 730 

Hammerschlag's  table  for 732 

Hsemogiobinometer    730, 732 

Hsemoglobinuria   666,  897 

intermittent    850 

paroxysmal    666 

Hsemometer   730 

Hemophilia      distinguished      from 

leukaemia   767 

from  purpura 767 

H-semoptysis     299 

in   typhoid 793 

Hair,    falling    of 507,882,907 

grayness  of 65 

Handwriting,  alteration  of 216 

Hay-asthma     230 

Hay-fever 79,  230 

distinguished    from    catarrhal 

fever   787 

Head,     enlargement     of,     diseases 

characterized  by 217 

gouty  inflammation  in 777 

rhythmic  movements  of 150 

shapes  of,  in  disease 218 

Headache   71 

congestive 71 

from   astigmatism 71 

from  Bright's  disease 690 


INDEX. 


941 


Headache  from  eye-strain 77 

from   lithsemia 778 

from  occlusion  of  frontal  sinus .  .    228 

from  poisoning 72 

in  diseases  of  the  brain 71 

nervous  and  neuralgic 72 

sick   72 

sympathetic 72 

Hearing,  derangement  of 85 

Heart,    anatomy    and    physiology 

of    .., 367 

aneurism  of 408 

atrophy  of 416,  752 

auricle  of,  dilated 437 

auscultation  of 373 

chronic     diseases     of,     with     in- 
creased percussion  dulness .  .  .   409 

clots  of  fibrin  in 396 

coagula  in  right  side  of 760 

dilatation   of 412,  413 

diseases    of 367 

associated  with  asthma 289 

with  diseases  of  colon 555 

confounded   with   intermittent 

fever   839 

with  pernicious  anaemia ....    744 

with  trichiniasis 925 

presenting   pain 3t)3 

symptoms   of 381 

displacements    of,    diseases    pre- 
senting      352,  431 

dropsy     caused     by     disease     of 

382,691,716 
enlargement  of,  symptoms  of .  .  .   417 

mistaken  for  aneurism 435 

without    pain 383 

examination  of 369 

fatty    accumulation    on 416 

fatty  degeneration  of 385,  414 

functional   disorders   of....   388,419 

gallop  rhythm  of 387 

gouty    411,777 

associated     with     contracting 

kidney    411 

hemisystole    of 389 

hypertrophy  of 409,  691 

impulse    of 371,  391 

inflammation  of 407 

inspection  of 370 

irregularity  of  action  of 388 

irritable   386,  391 

malformations    of 418 

causing  abscess  of  brain....      419 

miti'al  disease  of 417,  424 

murmurs    376 

endocardial    37fi 

pericardial   380 

seat    of 378 

musical  tone  in 421 

organic  diseases  of 393 

overaction    of 392 

pain  in  region  of 383 

palpation   of 370 

palpitation   of 386,  388 

paralysis  of,  in  relapsing  fever.  .    820 


Heart,   percussion    dulness  of,   in- 
creased       409 

percussion   of 371 

rhythm    of 387,  388 

rupture   of 416 

sounds    of 373,  375 

starvation    415 

strain    392 

topography  of 368 

valvular  affections  of 417,  426 

Heart-burn    477 

Heart-clot,   in   pneumonia 338 

Heat    exhaustion 182 

Heberden's    nodes 779 

Hectic    fever    distinguished    from 

intermittent    fever 838 

Hemiansesthesia    66 

Hemianopsia   53,  81,  84,  103,  106 

Hemiatrophy,   facial 131 

Hericrania   72,  223 

distinguished   from   pain   of   or- 
ganic cerebral  aft'ections ....   223 

from  periostitis 224 

from  rheumatism  of  the  scalp .    223 

Hemiparaplegia    100 

Hemiplegia    98 

alternating 99 

anatomical  diagnosis  of 100 

appearance  of  muscles  in 104 

cerebral    129 

corpus  striatum  in 100 

cortical 102 

electricity  as  a  test  of....    100,104 

feigned    104 

following  epilepsy 185 

lesions  of  internal  capsule.  .  .    102 

of  crus  cerebri 101 

of  gray  central  ganglia 102 

of  motor  zone 102 

of  optic  tract 103 

of  pons  Varolii 100 

of  praefrontal  lobes 103 

hysterical   118 

in   diphtheria 451 

in  the  course  of  typhoid  fever.  .    797 

nature  of  lesions  in 103 

optic  thalamus  in 100 

pain  in 104 

pathological  diagnosis  of 103 

rigidity  in 104 

spinal    100 

Hemorrhage,  a  cause  of  apoplexy..    167 

cerebellar   170 

cerebral    167,  172 

cortical 171 

from  aneurism 301 

from   bladder    664,  608 

fi'om    intestines 559 

from    kidneys 064 

from  larynx  and  trachea 300 

from    lungs 299,  301 

from   nose 230,  300 

from   oesophagus 300 

from  oral  cavity 300 

from  prostate  gland 668 


942 


INDEX. 


Hemorrhage  from  stomach  300,482,  495 
distinguished   from   irritant 

poisoning    894 

from    urethra 668 

from  uterus  in  myxcedema 718 

from  ventricles  of  the  hrain 170 

gastric    483 

in  apoplexy,  seat  of 169 

in   yellow   fever ' 824 

into  cerebrum  ovale 171 

into  corpora  quadrigemina 170 

into  internal  capsule 170 

into   lung   texture -. 339 

into  medulla 171 

into  pons 170 

into  thalamus 170 

limited  to  arachnoid 171 

to  one  crus  cerebri 171 

of  bowels 559 

punctiform 158 

renal,    clots   in 664 

retinal 82 

spinal   107 

ventricular 170 

vicarious    300,  483,  494 

Hemorrhagic  diathesis 908 

malarial    fever 849 

confounded   with   intermittent 

hsemoglobinuria     850 

with  yellow  fever 850 

pachymeningitis    171 

Hemorrhoids   550,  558,  559 

Hepatic   abscess 539,  573,  586 

diseases  as  complications  in  ty- 
phoid     ! .    799 

chronic  and  acute,  confounded  5  <  o 

dropsy 717 

fever   579 

confounded   with   intermittent 

fever   839 

neuralgia   516 

Hepatitis,  acute 572 

confounded   with   acute   infec- 
tious   jaundice 576 

with  acute  non-hepatic  dis- 
eases  with   jaundice 575 

with  cancer  of  liver 596 

with  chronic  hepatic  disease 

with  acute  s^miptoms.  .  .  .  575 
with  diaphragmatic  pleurisy  575 
with    inflammation    of    the 

biliary  passages 579 

with    inflammation    of    the 

portal  A-eins 574 

with    perihepatitis 573 

with  pigment  liver 574 

with  pylephlebitis 574 

chronic    • .  .  .  .    586 

interstitial   597,  607 

subacute  infectious 606 

suppurative    574 

syphilitic   608 

Hernia,  diapliragmatic.  confounded 

with   pneumothoiax 356 

omental,  dislocating  stomach...   506 


Hernia,    strangulated,    confounded 

with   colic 515 

with  intestinal  obstructions  542 
with  irritant  poisoning.  .  .  .    894 

through  the  recti  muscles 591 

Herpes    814,  878,  881 

labialis 879 

zoster    151,  879 

distinguished  from  erysipelas.   870 

from  scabies 879 

ophthalmicus   78 

pain  in,  mistaken  for  pleurisy  879 

Hiccough    203 

in  diaphragmatic  pleurisy.  .    204,  575 

Hip-joint   afi:ections 225,  539 

confounded  with  sciatica 225 

History  of  patient 26 

Hodgkin's  disease.     See  Lymphade- 

noina     749 

Hour-glass  stomach 508 

Hutchinson's   teeth 123,  781 

Hvdatid   cysts 505,  917 

"thrill  627 

tumor   of  kidney 707 

Hydatids  of  the  liver.  .  .  .    587,  600,  916 
distinctive    character    of    fluid 

in 602,917 

multilocular    602 

of    peritoneum 627 

Hvdrarthrosis   152 

Hydroa     880 

Hydrocephaloid  disease 162 

Hvdrocephalus.   acute 162 

'chronic   ' 161,  217 

Hvdrochloric  acid  in  gastric  juice 

473,  486,  492,  499 

Hydronephrosis    602,  706,  712 

confounded  with  hydatid  tumor 

of   kidney 707 

with  renal  cysts 707 

with   diuresis    712 

Hydrophobia   201,  460 

distinguished  from  hysteria 202 

from  strychnine  poisoning.  .  .  .    902 

from  tetanus 201 

Hydrorrhcea,  nasal 230 

Hydrothorax       confounded       with 

chronic   pleurisy 363 

Hyperfemia  of  stomach,  active.  .  .  .   482 

H^-perfesthesia     64,  93 

general    65 

hysteria  as  a  cause  of 65 

one-sided    65 

Hyperalgesia   65 

HA'pertrophv  of  brain 218 

of  heart.'. 409 

of  skin 886 

Hypochondriasis   145,  488 

Hj'pochondrium.  tumors  of 617 

Hypogastric  region,  tumors  of .  .  .  .    626 

Hypoleukfemia.    false 746 

Hypotonia 139 

Hysteria 142,  193 

abdominal,  confounded  with  peri- 
tonitis    530,540 


INDEX. 


943 


Hysteria  after  railway  accidents.  .  196 

associated  with  chronic  diuresis.  712 

with  membranous  diarrhoea.  .  556 

with  muscular  atrophy 130 

cerebral,  distinguished  from  apo- 
plexy    176 

from    chorea 194 

from  epilepsy 187,  194 

confounded       with       tubercular 

meningitis   163 

feigned    197 

resembling  hydrophobia 202 

locomotor   ataxia 142 

toxic    196 

traumatic 120 

A'isceral     479 

Hysterical  complaints,  local 195 

fever 196 

headache 196 

laughter    195 

locomotor  ataxia 142 

paralysis 118 

pseudo-maladies    196 

tetanus   198 

Hystero-epilepsy 195 


Ichthyosis    151,  883 

Icterus   567 

catarrhalis  577 

distinguished  from  abscess  of 

liver    579 

from  biliary   calculi 579 

from  cancer  of  liver 579 

from    cirrhosis 579 

from  congestion  of  liver...  578 

from  hepatic  fever 579 

Ileum,   catarrh  of 522 

ulceration    of 536 

Iliac  fossa,  disease  in 532 

pain  and  tenderness  in 532 

region,  tumor  of 625 

Impetigo 881 

contagiosa    881 

Incontinence  of  urine 615,  712 

india-rubber    poisoning 908 

Indican  in  urine 654 

Indigestion,    functional 489 

Infantile  paralysis 133 

scur\^     765, 782 

Infarct,    hemorrhagic 340 

Influenza    786 

See  also  Catarrhal  fever. 

Innominate,  aneurism  of 442 

Inosite    658 

Insanity   59 

chronic   157 

confounded  with  delirium 61 

following  acute  rheumatism.  .  .  .  771 

hysterical  196 

Insensibility     from     drink     distin- 
guished   from    apoplexy 173 


Insensibility    from    narcotics    dis- 
tinguished from  apoplexy 173 

Insolatio.     See  Sunstroke. 

Insomnia    63 

Inspiration,  jerking 277 

Insufficiency  of  aortic  valves  con- 
founded with   aneurism 436 

Intellection,   deranged 59 

Intermittent   fever 836 

apyrexia  or  intermission  in .  .  836 
distinguished    from    chills    of 

pus    formation 838 

from  diseases  of  the  heart .  .  839 

from  hectic  fever 838 

from  hepatic  fever 839 

from  passage  of  gall-stones  839 
from      puerperal      malarial 

fever   840 

from  remittent  fever 843 

from   syphilitic   fever 839 

from  urethral   fever...*...  839 

periodicity    in 840 

types  of . ' 836 

double    tertian 836 

quartan    836 

quintan 836 

quotidian   836 

tertian    836 

Intestinal  sand 509 

Intestine,  cancer  of 628 

constriction  of 548 

dilatation   of 507 

confounded  with  dilatation  of 

stomach    507 

diseases  of 508 

hemorrhage   of 545,  559,  793 

distinguished       from      hemor- 
rhoids     559 

inflammation  of 520 

internal   strangulation  of 546 

intussusception  of 537,  544,  547 

invagination    of 544 

mechanical  changes  in 552 

morbid    discharges    from 553 

obstruction    of 540 

causes  of 544 

confounded  with  peritonitis..  541 

with  strangulated  hernia.  .  .  542 

frequency  of 548 

from   fecal   accumulations  547,  548 

from  large  gall-stone 547 

from    stricture 547 

from   volvulus 546 

location  of  lesion  in 549 

percussion    of 467 

perforation   of 524 

associated  with  typhoid 800 

distinguished   from  colic 515 

from  irritant  poisoning.  .  .  .  894 

sloughing  of 545 

small   469 

stricture    of 547 

tubercular  disease  of 555 

worms    in 913 

Intoxication  63 


944 


INDEX. 


Intracranial  tumor 158 

Intrahepatic  concretion 839 

Intrathoracic  morbid  growth 433 

Iris-contraction 87 

Iritis     778 

Irritant   poisoning 893,  925 

Itch   875,  889 

army     ; 889 


J- 


Jaundice    567 

acholuric    568 

acute  infections 576 

catarrhal    577 

distinguished   from   cancer   of 

liver    596 

from  congestion  of  liver .  .  .  578 

from  remittent  fever 843 

deep,  diseases  marked  by 582 

diagnosis    of 568 

fatal  forms  of 571 

from  blood  poison 570 

from  mental  emotion 570 

green  or  black 571 

in  acute  non-hepatic  diseases.  .  .  575 

in  cancer  of  liver 594 

in  hepatic  disease 603 

in  phosphorus  poisoning 895 

Jaw,    kunpy 909 

Jaw-jerk 88 

Joint,    pysemic 770 

Joint-inflammations 131 

Justus's  sign 255 


K. 


Kakke 132 

Keratitis    79 

Kernig's   sign 155,  813 

Kidney,  abscess  around 537 

abscess    of 537,  702,  706 

distinguished  from  cystitis .  .  .   703 

affections  of,  with  swelling 505 

in   lead   poisoning 906 

calculus  in,  symptoms  of 679 

cancer  of .  .  . 692 

distinguished     from     enlarged 

spleen    618 

congestion    of 675 

contracted    697,  712 

associated    with     albuminuric 

ulceration  of  bowel 555 

with   gout 777 

confounded  with  myxcedema.  .    718 
with  pernicious  anaemia  .• .  .  .    743 

diuresis    in 712 

cysts  of 692,  693 

displacement    of 506,  622 

distinguished   from   epigastric 

tumor 622 

simulating    gall-stones 623 

enlarged,  chronically  inflamed. .  .    695 


Kidney,  enlarged,  confounded  with 

cancer  of  liver 599 

with   hydatids   of   liver ....   600 

with  ovarian  tumor 625 

fatty,  enlarged 695 

fibroid     698 

floating     537 

hemorrhage  from 665 

hydatids   of 707 

confounded  with  hydronephro- 
sis      707 

inflammation  of,  painful 675 

of   pelvis   of 706 

irritation,     distinguished     from 

sciatica  225 

movable  or  displaced 623 

simulated  by  displaced  spleen  624 
by     malignant     disease     of 

colon   624 

mucous  casts  of  tubules  of ...  .    696 

neuralgia   of 677 

pain   in 676 

confounded  with   colic...   516,676 

paroxysmal    676 

persistent     678 

percussion    of 467 

sarcoma    of 692 

suppurative  inflammation  of .  .  .  .    702 

surgical    694 

syphilomata   of 692 

tubercular  disease  of 666,  692 

confounded     with     Bright's 

disease    693 

tumors    of 537 

waxy  or  amyloid,  enlarged 696 

Klebs-Loeffler  bacillus. .  .  .    230,  245,  447 

Knee-jerk 87 

Kreatin  and  kreatinin 650 

L. 

Lab-ferment    474 

Lachrymation   152 

Lactation,      discoloration     during, 
distinguished      from      Addison's 

disease    753 

Lactic  acid 472,  499 

Landry's  paralysis 108 

Laryngeal  affections,  acute 240 

cough    234 

crises 140 

diphtheria    249, 454 

image    237 

paralysis 251 

phthisis 255 

rheumatism   241 

spasm   244 

from  use  of  antipyrin 900 

stenosis 256 

stridor    233,  245 

vertigo    76, 245 

Laryngismus  stridulus 244 

Ijaryngitis,    acute 240,  246 

distinguished  from  acute  pul- 
monary aft'ections 240 


INDEX. 


945 


Laryngitis,     acute,     distinguished 

from  pharyngitis 241 

from  tonsillitis 241 

chronic  249 

aneurism  of  aorta  confounded 

with    250,  439 

confounded  with  nervous  apho- 
nia      250 

of    epiglottis 253 

diffuse   cellular 241 

diseases  confounded  with 250 

erysipelatous  241 

feigned   253 

hemorrhagic 241 

hiemalis    241 

membranous 249 

(Edematous 242 

secondary,  of  the  exanthemata .  .    246 

sicca    241 

spasmodic 251 

syphilitic  or  tubercular. . 255 

Laryngoscopy    234 

Larynx,  abscess  of 248 

actinomycosis  of 248 

affections  of  nerves  of 251 

cancer  of 256 

cartilages  and  perichondrium  of, 

diseases    of 254 

changes  in  breathing  in  diseases 

of 233 

in  voice  in  diseases  of 233 

diseases   of,   acute 239,  240 

chronic   239,  249 

organic     239 

examination   of 238 

extirpation   of 254 

growths  in 256 

inflammation  of 243 

myxomata   of 257 

neuroses  of,  sensory 253 

oedema   of 242,  247 

pachydermia  of 256 

pain  in  diseases  of 234 

papilloma  of 257 

paralysis  of  muscles  of 251 

polypi   in 257 

sarcoma   of 257 

stenosis   of 256 

tubercle    of 255 

tumors    of 256 

ulcer   of 242,  256 

venous  congestion  of 253 

ventricular   banas   of,   hypertro- 
phy   of 254 

Lathyrus    sativus 107 

Lead    poisoning 513,895,905 

paralysis    from 92,121,906 

Lentigo     884 

Leontiasis 219 

Lepra,   or   leprosy 885 

Leptomeningitis,  acute 155 

Leptothrix   459 

Lethargy 183 

African   184 

Leucine    583,  639,  652 

59 


Leucocytes,  classification  of 735 

counting    of 726,  745 

decrease  in  number  of 746 

jn    gout 776 

in  the  urine 669 

intermediate  or  transitional ....   736 

phagocytic    735 

staining    of 734. 

Leucocytosis    535,  741,  745,  839,  841 

in  scarlet  fever 855 

in    trichiniasis 922 

Leucopenia    746 

Leukaemia 82,  746 

acute     749 

distinguished    from    hasmophilia 

and  purpura 767 

from   pernicious  anaemia 745 

false   hypo- 746 

lymphatic    747, 748 

medullary    742,  748 

myelogenous    747 

of    liver 593 

pseudo-leukaemia      distinguished 

from    745,  750 

retinitis    in 82 

splenic    747, 743 

Lichen    875 

planus     876 

ruber  875 

scrofulosorum 876 

syphilitic   892 

Lipoma  of  intestine 546 

Lithaemia    777 

associated     with     disorders     of 

vision    778 

with   gout 777 

with    pain    in     stomach    and 

bowels 778 

vertigo    in 74 

Liver,  abscess  of 539,  573,  586 

discharging  externally 590 

distinguished  from  appendici- 
tis       539 

from  hydatids 601 

pyaemic . .   573 

tropical    573 

actinomycosis    of 588 

acute  affections  of 572 

confounded  with  pyaemia.  .  .    756 
congestion   of...    572,593,596,843 
confounded    with    cancer   of 

liver    596 

with   remittent   fever 843 

inflammation  of 572 

distinguished     from     catar- 
rhal   icterus 579,596 

yellow    atrophy    of 577, 579 

confounded      with      typhoid 

fever   583 

with    yellow    fever 583 

from  phosphorus  poisoning.    584 

nervous  symptoms  in 582 

cancer  of 579, 588,  593 

distingui.shed   from  other  dis- 
eases      595, 601 


946 


INDEX. 


Liver,   chronic  affections  of 584 

with  acute  symptoms 575 

atrophy  of 610 

congestion   of 578,584,593 

confounded,   with    cancer   of 

liver    595 

wita  catarrhal  icterus..  .  .  578 
with  chronic  gastritis...  585 
with  hypertrophy  of  liver  585 

with  torpor  of  liver 585 

nervous  symptoms  in 585 

cirrhosis    of 579,  604 

from  malarial  infection 607 

hypertrophic    606,  608 

decrease  in  size  of 582,  604 

diseases  of 567,  571 

associated    with    bronzing    of 

skin  753 

dropsy  in 605,  717 

fever   in 579 

from   spirit   drinking 604 

jaundice  in 567,  572 

pain  in 567,603 

with  absence  of  jaundice.    584,603 
displacement    of,    diseases    pre- 
senting       352 

from  tight  lacing 585 

enlargement   of 362,  572,  584 

confounded  with  chronic  pleu- 
risy     362 

fatty  592,  593 

confounded   with    cancer 595 

fibro-fatty    607 

hobnail    604 

hydatids  of 587,  600,  607 

hypertrophy  of 585 

inflammation  of 573,  586 

subacute  infectious 606 

leuksemic    593 

movable    624 

percussion    of 465 

pigment,  confounded  with  acute 

hepatitis    574 

pysemie  abscess  of 591 

red  atrophy  of 608 

simple  induration  of 608 

syphilitic   593,  597 

confounded     with     cancer     of 

liver    597 

table  of  diseases  of 571 

torpor    of 585 

tropical   abscess   of 573,  591 

vessels  of,  embolism  of 762 

waxy     592, 595 

confounded  with  cancer 595 

diseases   confounded  with ....    593 
Lock-jaw.     See  Tetanus. 

Locomotor  ataxia ■ .    110,  138 

arthropathies  of,  distinguished 

from  arthritis  deformans..    779 
diminution  or  loss  of  muscu- 
lar sense  in 142 

distinguished   from   diphtheri- 
tic   paralysis    142 


Locomotor     ataxia     distinguished 
from  diseases  of  the  spinal 

cord     141 

from    disseminated    cerebro- 
spinal  sclerosis 141 

from    general    paralysis    of 

the    insane 140,  216 

gait  in 28,  139,  143 

gastric  crises  in 140,  496 

of  syphilitic  origin 143 

resembling    hysteria 142 

station    in 29 

Lumbago    773 

Lumbar    puncture 815 

region,  tumors  of 624 

Lungs,   abscess   of 327 

actinomycosis    of 329 

acute  affections  of 331 

confounded  with  tubercular 

meningitis    163 

in   typhoid  fever 804 

cancer  of 324,  360,  364 

cirrhosis  of 365 

collapse    of '.  .  .    311,366 

congestion    of 339 

diseases   of    260, 287 

physical  signs  of 285 

principal  symptoms  of 287 

engorgement  of,  in  fevers 338 

fistulous   opening  into 366 

gangrene  of 295,  308,  328 

hydatids    of 362 

hypostatic  congestion  of 561 

inflammation  of 334 

oedema   of 338,  685 

scrofulous  disease  of 330 

syphilitic  disease  of .  .  . 324 

tuberculosis  of 313,  331 

See  also  Phthisis. 

Lupus    884, 885 

Lymphadenoma 118,361,434,749 

distinguished     from     lymphatic 

cancer   750 

from  malarial  affection 750 

Lymphatic  glands,  cancer  of.  .    625,  750 

system,  disease  of 886 

Lymphocytes,    small 736 

Lymphomas,  local  gland 750 

distinguished     from     Hodgkin's 

disease    750 

of  mediastinum 434 


M. 


Maculae 884 

Malaria    758 

associated  with  hepatic  fever.  .  .    580 
with  pulmonary  cirrhosis ....   366 

with  typhoid  fever 806 

blood  in 853 

chronic    83.716,850 

Plasmodium  of 758 

simulating  passage  of  renal  cal- 
culus       677 


INDEX. 


947 


Malarial   cachexia 850 

cirrhosis    from 607 

changes  in  kidneys 850 

corpuscles  in  blood 833 

fever,  distinguished  from  dengue  830 
followed  by  skin  bronzing.  .  .  .    753 

puerperal 840 

hsematuria 667 

neuralgia   851 

palsy   b51 

.      parasite    347, 833 

poisoning,  chronic 716,  850 

symptoms  in  pneumonia 346 

Malignant    disease    mistaken    for 

pernicious    anaemia 744 

pustule   ■ 909 

Malta    fever 831,  832 

Mania,  acute 166,  456,  795 

alcoholic     164,  167 

confounded  with  acute  meningi- 
tis        166 

with  delirium  tremens 166 

ursemic    687 

Mania  a  potu 164,  167 

Marasmus    212 

Marrow    cells 748 

Mast  cells 736 

McBurney's   point 533 

Measles     858, 862 

among  soldiers 860 

associated  with  acute  bronchitis 

and    pneumonia 341,  860 

catarrh  in 230,  859 

complications    of 342,  860 

distinguished      from      miliary 

fever   860 

from  rubella 861 

from  scarlet  fever 857 

from   smallpox 859,867 

from  typhus  fever 859,  863 

eruption  in 859 

German    861 

Koplik's  sign  in 859 

malignant,  confounded  with  cere- 

bro-spinal   fever 818 

Mediastinum,  abscess  of 434 

inflammatory   thickening  of ...  .   435 

tumor   of 361 

Megaloblasts    735,  742,  743,  744 

Megalocytes     '.  .  .    734,  743 

Megalogastria   507 

Megrim.    See  Migraine. 

Melsena 559 

Melancholia,  acute 167 

Melanin    635 

Melasma  884 

Membranous    croup 245 

Memory,  disordered 59,  186 

Meniere's    disease 73,74,86,586 

Meningitis,   acute 155,  326 

confounded  with  acute  mania.    166 

with  acute  softening 158 

with  apoplexy 171 

with   cerebritis 157,  158 

with  delirium  tremens 165 


Meningitis,  acute,  confounded  with 
head- symptoms  of  acute 

rheumatism   159 

of  acute  ulcerative  endo- 
carditis         160 

of  conti'-ued  fevers 159 

of  pericarditis 160 

of  pneumonia 160 

of  remittent  fever 844 

of  typhus  fever 809 

with  tetanus 199 

with  typhoid  fever 804 

cerebro-spinal    163,  812 

diseases  confounded  with 816 

distinguished  from  purpura..    767 

epidemic     812,  814 

sporadic   164, 817 

chronic,   distinguished   from   tu- 
mor        211 

epidemic     812 

idiopathic    817 

of  the  base  of  the  brain 156 

of  the  convexity  of  the  brain.  .  .  .    156 

ordinary    161 

pneumococcus    818 

serous   162 

spinal    113 

tubercular    160,  817 

distinguished    from    acute    af- 
fections of  the  lungs.    163,  334 
from  acute  hydrocephalus.  .    162 
from  cerebro-spinal   fever..    817 
from  chronic  hydrocephalus .    161 

from  hysteria 163 

from  ordinary  meningitis..  .    161 

from  pneumonia 162 

from  typhoid  fever. 162 

rose-spots  in 163 

suppurative  399 

Meningococcus    81.5' 

Meningo-encephalitis 187 

Mensuration  of  chest 264 

Mental   faculties,   diseases   charac- 
terized   by   gradual    impairment 

of     207 

Mercurial    salivation 445 

tremor    905 

Merycism    484 

Mesenteric  vessels,  thrombosis  of.    760 

Meteorism    523 

Metritis     confounded    with    acute 

cystitis    701 

with  peritonitis 527 

Microblasts    735 

Micrococcus   Melitensis 832 

Migraine    72,  84,  223,  690 

distinguished  from  frontal  sinus 

disease    228 

Miliaria   papulosa 891 

vesiculosa     891 

Miliary   fever 860 

Milk-leg.     See  Phlegmasia  alba  do- 
lens   721 

Milk-sickness     910 

Mind-blindness    85,  179 


948 


INDEX. 


Mitral  constriction   417 

Mollities    ossium 781 

distinguished  from  rickets...    781 

Molluscum  epitheliale 891 

iibroma   891 

Monoplegia    90,  104 

bracMo-facial 105 

crural 105 

facial 105 

facio-lingual    106 

oculomotor 106 

Morphine   habit 903 

Morphcea .   888 

Morton's    disease 775 

Morvan's   disease 132,  152 

Motion,   deranged 90 

voluntary,    diseases    marked    by 

sudden  loss  of 167 

Motor  path  of  Go-\vers 55 

Mountain    fever 806 

Mouth,  curd-like  exudation  of ...  .   443 

diseases  of 443 

gangrene   of 452 

inflammation    of 443 

morbid   appearances    of 443 

sore,   of   pregnancy 444 

tuberculous  ulceration  of 444 

Mucin 663 

Muco-enteritis 521 

]\lucus  in  stools • 509 

vomiting   of 481 

Multiple   neuritis...    109,130,142, 

451,717,906 

peripheral 717 

See  also  Neuritis. 

Mumps    446, 455 

See  also  Parotitis. 

confounded  Avith  erysipelas 870 

Murmur    respiratory 276 

■  vesicular    274 

absence  of 276 

changes  in 275 

Murmurs,    cardiac 376 

cardio-pulmonary 317 

endocardial    376,  395 

from  lung   changes 420 

from  misdirection  of  current.  .  .   419 

functional    valvular    419 

in  the  course  of  fevers 396 

musical   421 

over  thyroid  gland 438 

pericardial    380 

without  A'alvular  lesion 380 

Muscse  volitantes 76 

Muscle,  rectus,  contraction  of .  .  .  .    621 

Muscle-jerk    89 

Muscles,  appearance  of,  in  paraly- 
sis ' ;...      93 

morbid  states  of,  paralysis  from     91 

spasm   of 202 

wasting   of 128 

Muscular  contraction 90. 

confounded      with      epigastric 

tumor   621 

rheumatism   199 


Muscular  rigidity 104,  199 

sense   55,  69 

diminution  or  loss  of 142 

symptoms   in   trichiniasis 923 

Myalgia    221,  774 

Mvasthenia     gravis     pseudo-para- 

lytica    91,  128 

Myelitis   Ill,  114 

acute,  contrasted  with  acute  as- 
cending paralysis Ill 

contrasted  with  multiple  neu- 
ritis      Ill 

central    116 

disseminated    116 

from  compression 115 

hemorrhagic 115,  116 

transverse    115 

Mvcrocvtes 734 

Myelocytes   736,  748 

ilyocarditis,  acute 407 

associated  with  gonorrhoea 408 

chronic  408,  416 

rheumatic    771 

Myoclonus  multiplex 191 

Myopia    84 

Myotone,  congenital 203 

transient    203 

Myxcedema    219,  717,887 

distinguished  from  acute  nephri- 
tis       718 

from  contracted  kidney 718 

from    scleroderma 887 

Myxoma,   nasal 230,  231 


N. 


Nails,   state   of,   in   disease..    314, 

358,  367,  882,  907 

in  typhoid  fever  relapses 779 

Narcolepsy      distinguished      from 

sleeping   sickness 176 

from  trance 176,  184 

of  hysterical  origin 176 

Narcotics,  insensibility  from 173 

poisoning   by 897 

Nasal  catarrh 229 

cysts    232 

hemorrhage    230 

hydrorrhcea    230 

papilloma   232 

polypi 232 

sarcoma    232 

Nausea  as  a  svmptom 478 

Neck,  cellulitis  of 241 

Nematoda    913 

Nephralgia 676 

confounded  with  renal  colic  516,  676 

from  passage  of  calculi 676 

Nephritis    675,  905 

acute   painful 675 

distinguished      from      acute 

Bright's  disease 683 

from  acute  cystitis 701 

acute  parenchymatous 681 


INDEX. 


949 


Nephritis,    bacillosa     interstitialis 

primaria    682 

chronic  consecutive 69^ 

interstitial 697 

in  Weil's  disease 577 

suppurative   683 

Nerve-storm 223 

cardiac   387 

Nerves,  diseases  of 50 

paralysis  from  affections  of....      91 

wounds  of 151 

Nervous  affections,  classification  of  153 
deranged  nutrition  and  secre- 
tion in 151 

centres,    diseases   of,   anaesthesia 

a  symptom  of 66 

paralysis  from 90 

exhaustion   162 

prostration 207 

system,  diseases  of 59 

disturbance  of,  in  typhoid.  .  .  .    795 

syphilitic  affections  of 122 

Nettle-rash.     See  Urticaria. 

Neuralgia  220 

abdominal    518,  630 

due  to   aneurism 630 

affecting  urinary  passages 221 

as  a  cause  of  headache 71 

cerebral 223 

confounded  with  aneurism 630 

with  pain  of  rheumatism     220,  773 

dor  so-intercostal     151,  518 

epileptiform 222 

facial     221 

disting-uished      from      painful 

anaesthesia  of  fifth  nerve.   222 

from  spasm  of  face 222 

from  decayed  teeth 222 

hepatic    516 

in  Bright's  disease 690 

intercostal   352,  386 

distinguished  from  acute  pleu- 
risy       352 

from  angina  pectoris 386 

from  gastralgia 487 

lumbo-abdominal    518 

of  bladder 701 

of  dorsal  and  lumbar  nerves.  ...   518 

of  frontal  sinus  disease 228 

of  kidney 677 

of  mesenteric  or  solar  plexus.  .    519 
of  spinal  nerves  confounded  with 

colic    518 

of    stomach 485 

ovarian • 518 

reflex 221 

sciatic   151 

supra-orbital   228 

trigeminal    152 

Neurasthenia    204 

cerebral    205,  206,  210 

sexual   206 

spinal    206 

Neuritis    213,  220 

acute   progressive 109 


Neuritis,  brachial    226 

due  to  diphtheria 112 

general  crural 226 

multiple    109,  130,  142,  451,  717,  906 
distinguished    from    acute   as- 
cending paralysis Ill 

fi'om  acute  myelitis Ill 

from  locomotor  ataxia 110 

from   rheumatism 110 

of  diabetes 112 

optic   83,  158,  209,  213 

Neuromyositis  227 

Neurosis,    cardiac 386 

cutaneous   881 

occupation .    192 

reflex     78, 84 

vasomotor    385,  722 

Night-blindness  84 

Night-terrors 61,  231 

Nodes,   Heberden 779 

Nodules    connected    with    rheuma- 
tism        771 

in   leprosy 885 

subcutaneous   fibrous 395 

syphilitic,  of  lung 324 

Normoblasts    735,  744 

Nose,  diphtheria  of 229 

diseases  of 228 

foreign  body  in 229 

gonorrhceal  infection  of 230 

hemorrhage    from 230,  607 

Nucleo-albumin     663 

Nimibness  of  extremities 70,  142 

Nutrition,  deranged 151 

Nutritional  disease  of  spinal  cord.    206 
Nystagmus 141,  150,  191 


Occupation  neuroses 192 

Ocular  mechanism,  derangement  of     77 
Odor  of  bodv,  in  Addison's  disease  752 

CEdema   .  .  .  ." 715 

angio-neurotic   152,  519,  870 

distinguished  from  colic 519 

from    erysipelas 870 

in    trichiniasis 923 

of  ankles 500,  715 

of  forehead  and  eyelids 212 

of  larynx 240,  242 

diagnosticated  from  croup. .  .  .   247 

pulmonary   338,  685 

mistaken  for  pneumonia 338 

occurring   in   Bright's   disease  685 

CEsophagitis    459 

CEsophagus,  auscultation  of 461 

cancerous  narrowing  of 460 

cicatrices    of 460 

compiession  of 460 

dilatation  of 460 

diseases  of 443,  458 

use  of  sound  in 461 

diverticula    of 471 

inflammation  of   459 

rupture  of 460 


950 


INDEX. 


Oesophagus,,   stricture  of 459,  502 

spasmodic    460 

tliicl-cening  of,  from  poisoning.  .    894 

Oidium   albicans 444 

Omentum,  cancer  of 505,  599 

distinguished   from   cancer   of 

liver    599 

Ophthalmia,    gonorrhoeal 79 

neonatorum    79 

Ophthalmoplegia    81 

Ophthalmoscope  in  diseases  of  the 

nervous  system 78,  81 

Opisthotonus    198 

Opium  poisoning 897,  902 

Optic  nerve,  atrophy  of 83,  139 

neuritis    83,  158,  209 

tract,  diseases  of  the 103 

Orthopncea 28,  288 

Orthotonos   198 

Osteitis  deformans 219 

Osteomyelitis,   acute 770 

Otitis  from  inveterate  smoking.  .  .   904 

Ovarian  cysts 538,  602,  707 

dropsy  confounded  with  ascites.    612 
fluid,  chemical  character  of .  .  .  .    613 

inllammation  518,  537 

neuralgia   518 

tumors    625 

simulating  renal  growths.  .  .  .    626 

Oxaluria     650,  676,  685 

Oxybutyric  acid 658 

Oxyuris   vermicularis 913 

Ozsena  231 


P. 


Pachymeningitis 156 

hemorrhagic  .' 114,  171 

spinalis  interna 114 

Paget's  disease 219 

Pain  as  a  symptom 48 

above  the  eye 228 

cardiac   383 

crises 140 

diseases  characterized  by 220 

gastric,  as  a  symptom 484 

in  chronic  rheiunatism 773 

in  diseases  of  the  liver....    567,603 

in  embolism  of  arteries 762 

in  laryngeal  affections 234 

in  region  of  heart 386 

in  typhoid  fever 795 

lightning 141 

paroxysmal,    diseases    character- 
ized by 220 

in  region  of  kidney 676 

Palate,   paralysis   of 450 

Palpation  of  the  chest 265 

Palpitation,    cardiac,    diseases    at- 
tended   with 386,  388 

Palsy.     See  also  Paralysis. 

associated  with  typhoid  fever.  .  .    796 

Bell's     105,  124 

bulbar 127 


Palsy   by   compression 126 

cerebral    135 

•   facial    124,  172 

double   125,127 

hysterical 118 

lead   121 

limited    118 

local 124 

of  the  arm 126 

pseudo-bulbar    127 

rheumatic    130 

shaking 144,  217 

wasting    128 

Pancreas,  calculous  diseases  of ...  .    620 

cancer  of 620 

cyst    of 620 

disease    of 619 

fat  necrosis  of 526 

fatty  degeneration  of 619 

diarrhoea    in 561 

ulcerating    484 

uniform  simple  hardening  of .  .  .   619 

Pancreatic  fat  necrosis 619 

Pancreatitis,    acute 526 

confounded  with  peritonitis .  .   526 

chronic   619 

hemorrhagic    526,  550 

suppurative     526, 620 

Papillitis    83,  213 

Papilloma    232,  257 

Papular   diseases 875 

Paracentesis    363 

Parsesthesia  70 

Paralysis    90 

See  also  Palsy. 

acute   ascending 108 

contrasted  with  acute  myelitis  111 

with  multiple  neuritis Ill 

agitans    144,  146,  217,  779 

distinguished  from  chorea.  ...    191 

from  general  paralysis 217 

from    rheumatism 779 

alternate 90 

asthenic  bulbar 128 

bulbar 127,128 

clinical  investigation  of 93 

complete   90 

crossed    90,  99 

diphtheritic   121,  142,  450 

due  to  multiple  neuritis 122 

electro-muscular        contractility 

and  sensibility  in 95,  97 

essential,  of   children 133 

facial     . 124 

following    measles 859 

from  affection  of  nerves  at  their 

extremities 91 

of  radial  nerve 121 

from  apoplexy 167 

from  chronic  softening 207 

from  compression 126 

from  exposure  to  cold 91 

from  interference  with  the  circu- 
lation          91 

from  lead  poisoning.  .  .  .    92.  121.  906 


INDEX. 


951 


Paralysis  from  lesion  in  the  course 

of    a   nerve 90 

from  lesion  of  crus  cerebri 101, 

from  lesion  of  nervous  centres. .  .      90 

from  lesion  of  spinal  cord 56 

from  morbid  state  of  the  muscles     91 

from  poisoning 92 

from  progressive  muscular  atro- 
phy        128 

functional     90 

general    '.  .   215 

of  insane 140,  215 

glosso-labio-laryngeal    127 

hereditary    91 

hysterical  118,  130, 196 

infantile   133 

infectious   112 

intermittent 92 

involuntary  movements  in 93 

local    130 

malarial     92, 851 

motor,  from  exposure  to  cold.  .  .      91 

of  arms 105 

of  leg  only 105 

of  median  nerve 126 

of  musculo-spiral  nerve 126 

of  nerves  of  arm 126 

of  radial 126 

of  sixth  nerve 80,  122 

of  third  nerve 80,  122 

of  ulnar  nerve 126 

of  vocal  apparatus 251,  290 

periodic 92 

pseudo-hypertrophic       muscular, 

29,  133,  408 

rapid  or  universal 123 

reflex 118 

rheumatic 120 

simulated 91 

spastic  spinal 116 

spinal,  general 129 

strabismus  from 79 

sudden,  extensive,  without  coma  175 
distinguished  from  apoplexy.  .    175 

syphilitic    122 

from  inherited  taint 123 

tabular  view  of 136 

tremor  in 144 

vasomotor    100 

with  muscular  wasting 128 

without  coma 175 

Paramyoclonus  multiplex 150 

Paramyotone 203 

Paraplegia  90,  106 

ataxic   141 

cervical   115 

following  accidents 120 

from  hypnotic  suggestion 120 

from  spinal  hemorrhage 107 

from  tumor  of  cord 117 

functional 120 

gradual   112 

hysterical 66 

reflex  118 

from  disease  of  the  bladder.  .  .    118 


Paraplegia,  reflex,  from  intestinal 

worms    118 

simple  senile 145 

sudden 107 

Parasites    893,  911 

aestivo-autumnal. .  .    835,  841,  846,  849 

anaemia  due  to 740 

animal    510,913 

diseases   caused  by 833,  888 

fly    918 

in  intestines 913 

in  sputum 297 

malarial    347,  833 

vegetable    888,911 

Parenchyma,  hepatic,  diseases  of.  .    571 

Paresis,  general 215 

spastic    132 

Parotitis    446, 455 

associated  with  pneumonia 336 

secondary   446 

See  also  Mumps. 

Pectoriloquy    284 

Pellagra    888 

Pelvic  cellulitis 626 

haemotocele 538 

peritonitis    539 

Pemphigus   879 

Peptone  in  leukaemia 746 

in  puerperal  state 662 

Peptonuria  in  phosphorus  poison- 
ing     895,  908 

Percussion   266 

auscultatory    269 

clearness  of,  as  a  diagnostic  sign  302 
dulness  of,  diseases  accompanied 

by    313,  362 

of  abdominal  viscera 465 

of  chest 266 

pitch  in 269 

respiratory 269 

Percussion-hammer    267 

Perforation,  intestinal,  confounded 
with    colic 515 

Periarteritis    719 

nodosa    ; 719,925 

Pericardial  adhesions 399,  405 

effusion    362,  399,  416 

mistaken     for     dilatation     of 

heart     416 

murmurs    380 

Pericarditis,   acute 399 

cancerous   405 

caused  by  scurvy 765 

diagnosticated  from  endocarditis  402 

from   gastric   irritation 404 

from  inflammation  of  brain .  .    404 

from  pleurisy 403 

friction  sounds  of 403 

head-symptoms     of,     confounded 

with  meningitis 160 

hemorrhagic    405 

in  Bright's  disease 685 

indurated  mediastino- 406 

plastic     404 

tubercular    405 


952 


INDEX. 


Pericardium,  adhesions  of 405 

dropsy  of 404 

effusion     of,     confounded     with 

chronic  pleurisy 362 

ulcerative  perforation  of 407 

Perihepatitis   573 

Perinephritis  703 

distinguished     from     inflamma- 
tion of  psoas  muscle 704 

Perineuritis 226 

Periodicity    in    non-malarial    dis- 
eases       840 

Periosteum,  rheumatism  of 775 

thickening    of 151 

Periostitis    224 

Peristaltic   unrest 479 

Peritoneum,  abscess  of 627 

carcinoma    of 614,  627 

colloid  cancer  of 627 

diseases  of 508,  613,  627 

dropsy  in 610 

fatty  tumor  of 627 

hydatid  disease  of 627 

perforation    of 515 

sarcoma    of 627 

Peritonitis,    acute 522 

associated  with  acute  pancre- 
atitis         526 

confounded     with     abdominal 

hysteria 530 

with  acute  enteritis 526 

with  acute  gastritis 525 

with   colic 519,531 

with    constipation 541 

with  cystitis 527 

with  distention  of  bladder.    527 
with   inflammation  and   ab- 
scess   of    abdominal    mus- 
cles        527 

with  intestinal  obstruction.   541 

with  metritis 527 

with  rheumatism  of  abdomi- 
nal walls 530 

with  typhoid  fever 803 

chronic    ' 531, 613 

cancer  in 532 

distinguished  from  cirrhosis .  .    609 
from  dropsical  effusion....    613 
from    collection    of    pus    in    the 

cavity   528 

local  or  partial 525 

pelvic    539 

perforative 524,  541 

puerperal   524 

subphrenic 589 

tuberculous   .  .    504,  532,  539,  614,  753 

Perityphlitis   535 

Pernicious    anaemia ;  .  .  .    740 

confounded   with   Addison's   dis- 
ease      754 

with  contracted  kidney 743 

with  disease  of  heart 744 

with  malignant  disease 744 

with  organic  disease  of  stom- 
ach      743 


Pernicious    ansemia    distinguished 

from  chlorosis    744 

from  leukaemia 745 

from  ordinary  anaemia 744 

from  pseudo-leuksemia 745 

retinitis  in 82 

state  of  blood  in 741 

Pernicious    fever 846 

algid   ■ 848 

cause    of 848 

cerebral    847 

confounded  with  cerebro-spinal 

fever   816 

gastro-enteric    847 

thoracic    847 

Pestis   major 830 

minor    831 

Petit  nial 185 

Pettenkofer's   test 654 

Phantom  tumors 621 

Pharyngeal    fever 870 

tonsil 231 

Pharyngitis    241,  451 

confounded  with  diphtheria....   451 

sicca    241 

Pharyngo-mycosis 459 

Pharynx   and   cesophagus,   diseases 

of  443,  458 

adenoid  vegetations  in 740 

Phenylhydrazine   test 657 

Phlebitis    408,  721,  759 

gouty 722 

Phlegmasia  alba  dolens.  .    721,  740, 

759,  769 
associated  with  gastric  can- 
cer     760 

confounded  with  rheumatism  769 
Phonendoscope  of  Bianchi  272,  372,  465 

Phosphates  in  the  urine 645,  676 

alkaline  and  earthy 645 

calculi  composed  of 676 

Phosphatic  diabetes 647 

diathesis 647 

Phosphorus   poisoning 895 

Photophobia 293 

Phtheiriasis 875,  876,  888 

Phthisis    313 

See  also  Tuherculosis  of  lungs. 

acute     305,  332,  805 

associated  with  typhus 810 

distinguished  from  meningitis  334 
from  typhoid  fever.  .  .  .   333,  805 

acute   pneumonic 333 

bronchial    293 

cavity  from,  distinguished  from 

pulmonary    abscess 327 

chronic   313 

confounded  with  actinomycosis.   329 
with  bronchial   dilatation.  .  .  .   325 

with  chronic  bronchitis 319 

with  clironic  pleurisy.  .  .  .    323,  360 
with    chronic   pneumonic    con- 
solidation         320 

with   pulmonary  abscess 327 

with  pulmonary  cancer 324 


INDEX. 


953 


Phthisis    confounded  with    pulmo- 
nary gangrene    328 

with  syphilitic  disease  of  the 

lungs     324 

cough  in 313 

fibroid     365 

laryngeal    255 

of  old  people 320 

physical  signs  of 316 

pneumonic    322,  333 

retrogression  of 330 

skin   bronzing   in,    distinguished 

from   Addison's   disease 753 

Physical  diagnosis,  methods  of ...  .   260 

Pigeon  breast 781 

Pigment  in  the  blood 764,  851,  853 

in  the  skin 709,  751,  884 

liver    574 

Piles   551,  558 

Pityriasis   capitis. 890 

maculata  et  circinata 882 

rosea 882 

rubra    878,  882 

versicolor   890 

distinguished    from   Addison's 

disease    753 

Plague    830 

distinguished  from  typhus  fever  831 

from  yellow  fever 826 

Plasmodium   malarias 758 

Pleura,    cancer   of 361 

effusion    into 310,312,323, 

349,  358,  363,  589 

fistula  of 366 

friction  sound  in 403 

liquid    in 403 

Pleurisy,   acute 340,  348 

confounded  with  acute  Bright's 

disease    685 

with  acute  pneumonia 351 

with   intercostal   neuralgia.   352 

with   pleurodynia 352 

bilious 346 

chronic    323,  357,  363 

confounded    with     abscess    in 

thoracic    walls 362 

with   cancer 361,  364 

with      chronic      interstitial 

pneumonia   364 

with  cirrhosis  of  lung 365 

with  collapse  of  lung..    311,366 

with   emphysema 360 

with  enlargement  of  liver..    362 
with  enlargement  of  spleen  362 

with  fistula  of  pleura 366 

with  hydatid  cysts 362 

with    hydrothorax 363 

with   intrathoracic  tumor..    360 
with  pericardial  effusion .  .  .    362 

with   phthisis 323 

with   pneumothorax 360 

with   tubercle 364 

diseases  confounded  with 360 

circumscribed    301 

diaphragmatic    575 


Pleurisy,  different  forms  of 359 

double     324 

dry  stage  of 348, 306 

associated  with  typhoid  fever  804 

effusion,  stage  of 349 

encysted    361 

fluid  of,   microscopical   and  bac- 
teriological examination  of .  .  .    359 

idiopathic    350 

plastic    366 

tubercular    323,  363 

Pleuritic  effusion...    310,312,323, 

349,  358,  363,  589 

Pleurodynia     352 

confounded  with  acute  pleurisy  352 

Pleurothotonos    198 

Pleximeter   372 

Plica    polonica 891 

Pneumatometry    265 

Pneumococcus  of  Fraenkel...    298,342 
of   Friedlaender .  .  .    232,  299,  342,  815 

Pneumo-hydropericardium    400 

Pneumonia,    acute 334 

confounded    with    acute    bron- 
chitis        341 

with  acute  phthisis 340 

with  acute  pleurisy 351 

with  appendicitis 540 

with  cerebro-spinal  fever.  .  .    818 
with   hypostatic   congestion.  339 
with  pulmonary  apoplexy.  .    339 
with     pulmonary     engorge- 
ment in  fevers 338 

with  pulmonary  oedema.  .  .  .    338 
head-symptoms  of,  confounded 

with  meningitis 100,  163 

apex    338,  344 

aphasia  in 180 

aspiration    342 

associated  with  measles. 860 

with  typhoid  fever 804 

with  typhus  fever 810 

with  ulcerative  endocarditis.  .    342 

bilious    346 

broncho-    304,  312,  332,  341 

following     hemorrhage     from 

cavities   342 

temperature  chart  of 343 

catarrhal    304 

chronic,  confounded  with  phthi- 
sis     

chronic    catarrhal 

croupous 334. 

deglutition   

diplococcus    of 342. 

dissecting . 

double     

from  einbolism 

gangrenous     

hypostatic    

interstitial  

latent    

lobar    304, 

distinguished  from  collapse  of 
lung    311 


320 
322 
342 
341 
347 
328 
344 
340 
257 
339 
364 
344 
312 


954 


INDEX. 


Pneumonia,   malarial    346 

massive     351 

migratory    344 

physical  signs  of 336 

pneumocoecus   of 298,  342,  345 

tuberculous   aspiration   broncho-  342 

typhoid     345 

articular  symptoms  of 346 

Pneumonic  consolidation,  chronic.    320 

Pneumo-pericardium   406 

Pneumothorax    353,  360,  407 

chest  sounds  in 354 

diagnosticated       from       chronic 

pleurisy    360 

from   diaphragmatic   hernia.  .   356 

from  emphysema 310 

from  pneumo-pericardium ....   407 

physical  signs  in 354 

subphrenic   496,  590 

without    perforation 356 

Pneumo-typhus   805 

Podelcoma    912 

Poikiloblasts    735, 743 

Poikilocytes     734,  743 

Poisoning   173,  893 

aconite    901 

acute     893 

alcohol    173,  898,  903 

alkaline    894 

aloes    896 

ammonium  570,  894 

aniline    899 

antimony   895 

antipyrin 900 

arsenic    110,522,895,907 

atropine   899 

belladonna   899 

benzin     898 

bromine    895 

brucine     901 

by   poisonous   exhalations 910 

by  ptomaines 910 

Calabar    bean 901 

cantharides 896 

carbolic    acid 899 

carbon   dioxide 900 

disulphide    908 

monoxide   655,  900 

carbonic    acid 900 

oxide     900 

charcoal    fumes 900 

cheese,  egg,  milk. 


896 

chloral    .  ." 174,  898,  903 

chlorine    895 

chloroform     174,  898,  903 

chronic   902 

coal  gas 900 

colchicum 896 

colocynth    896 

conium    899 

copper     513, 570, 895,  907 

corrosive    sublimate 896,  905 

cream    puff 896 

diazobenzene   896 

digitalis   901 


Poisoning,    elaterium 896 

ergot   896,904 

ether   684,    898,  903 

from   alkalies 894 

from  alkaloids 910 

from  animal  effluvia 910 

from  ptomaines 910 

fungi     897 

hydrochloric  acid 894 

hydrocyanic    acid 174,  899 

hyoscyamus    899 

iodine    895 

iron 895 

irritant    563, 893 

jaborandi  901 

lead     121,  250,  895,  905 

lobelia 896 

malarial     716,  850 

mercurial   522,  895,  905 

muscarine    897 

mushroom    897 

narcotic    173,  250,  686,  897 

insensibility  from,  distin- 
guished from  alcohol- 
ism        898 

from   apoplexy 173,897 

from   uraemia 686,  897 

nitric  acid 459,  894 

nitrobenzole  174 

nitroglycerin  901 

opium    174,  897,  902 

oxalic    acid 894 

paraldehyde 904 

petroleum     900 

phosphorus    584, 895,  908 

picrotoxin    902 

pilocarpine 901 

potassium  hydroxide 894 

iodide  and  nitrate 894,  895 

producing  coma 63 

headache 72 

paralysis    92 

prussic    acid 174,  899 

sausage     896, 925 

savin     896 

sewer-gas    682 

silver    895 

slow,  by  metals 905 

sodium   hydroxide 894 

strychnine   901 

confounded  with  epilepsy ....    902 

with   hydrophobia 902 

with   tetanus 201,  901 

sulphuric    acid 459,  894 

tobacco    896,  904 

tyrotoxicon    896 

veratrum  viride 901 

zinc     895, 908 

Poisons   893 

animal,  diseases  caused  by 908 

irritant     893 

vegetable    901 

Poliomyelitis   116,  151 

acute    anterior 133,  135 

Polysesthesia   69 


INDEX. 


955 


Polyarthritis   • 242 

Polychromatophiles   735 

Polypi,  nasal 230,  232,  289 

of    larynx 257 

Polyuria   711 

chronic,  distinguished  from  true 

diabetes    712 

Porencephalus     218 

Porrigo    larvalis 881 

Portal   circulation,   disturbance  of  567 
veins,      inflammation      of,      con- 
founded     with      acute 

hepatitis 574 

with  cirrhosis  of  liver .  .  .  608 

inflammation  of,  with  coagula  608 

thrombosis    of 609 

Position  as  a  symptom 27 

Posterior  sclerosis 138 

Pregnancy,  discoloration  of  skin  in  753 
extra-uterine,   mistaken   for   ap- 
pendicitis     537 

sore  mouth   of 444 

Pressure-points 202 

Proctitis  558 

Progressive  muscular  atrophy  128,  134 
distinguished  from  bulbar  paral- 
ysis      130 

from  cerebral  hemiplegia 129 

from  general  spinal  paralysis  129 

from  hysteria 130 

from  infantile  paralysis 134 

from  joint  inflammations 131 

from  local  paralysis 130 

from  multiple  neuritis 130 

from      progressive      muscular 

dystrophy 133 

from  syringomyelia 131 

from     unilateral     progressive 

atrophy  of  the  face 131 

of  peroneal  type 132 

Prostate  gland,  hemorrhage  from.  668 

Prostatorrhcea 206 

Prurigo     876 

Pruritus     876, 892 

hiemalis    892 

in  diabetes 708 

Pseudo-disseminated  sclerosis 146 

Pseudo-leukaemia    748,  750 

splenic    750 

Pseudo-scarlatina   857 

Pseudo  tabes  mesenterica .  .  .  .   476,622 

Psoas  abscess    538 

muscle,  inflammation  of 704 

Psoriasis    876,  882,  883 

distinguished  from  eczema  squa- 
mosum      883 

from    lichen 876,883 

syphilitic    883 

Ptomaines 73,  551 

Ptosis   80 

Ptyalism    443 

Puerperal  malarial  fever 840 

Pulmonary    affections,    confounded 

with   laryngitis 240 

with  typhoid  fever 804 


Pulmonary  apoplexy 339 

cancer   324 

disease,  physical  signs  of 259 

engorgement    in    fevers 338 

symptoms  in  trichiniasis 924 

Pulsation,   abdominal 628 

aortic    628 

confounded  with   aneurism  of 

abdominal    aorta 630 

of   tumors    630 

Pulse,  condition  of,  in  disease 31 

dicrotic 34,  790 

frequency  and  rhythm  of 31,  32 

gaseous   33 

in   typhoid   fever 790 

resistance  of 33 

respiration-ratio,  perverted 334 

strength  and  volume  of 33 

Pulsus   alternans 32 

paradoxus    400 

Pupil,    Argyll-Robertson 81 

contraction  and  dilatation  of .  .  .      81 

Purging,  diseases  attended  by.  .  .  .    561 

Purpura     765 

acute,  distinguished  from  haemo- 
philia        767 

from    scurvy 765 

associated   with   colic 519 

haemorrhagica  and  rheumatica..    766 

Purulent    urine 668,  683 

diseases  associated  with 700 

Pus  formation,  distinguished  from 

intermittent  fever 838 

in  peritoneal  cavity 528 

in    stools 509 

in  urine 668,  700,  704 

in  vomit 481 

presence  of,  in  appendicitis 534 

Pustular  diseases 880 

Pustule,  malignant 909 

Pyaemia    754 

abscess    of 591 

arterial     756 

associated  with  myocarditis ....   408 

chronic  or  relapsing 757 

confounded  with  acute  affections 

of    liver 756 

with  acute  glanders  or  acute 

farcy     756 

with  intermittent  fever 838 

with  rheumatic  fever 755 

with  typhoid  fever 755 

idiopathic 756 

joint-afl'ection  of 770 

metastatic  or  embolic  abscesses 

of .    756 

spontaneous  septico- 757 

Pyelitis     704 

catarrhal   or   rheumatic 705 

from  irritation  of  calculi 706 

tuberculous    706 

Pylephlebitis     574 

Pylorus,  cancer  of 502 

fibroid  thickening  of 504 

Pyonephrosis 706 


956 


INDEX. 


Pyonephrosis  confounded  with  ab- 
scess of  the  kidney 706 

with  suppurative  nephritis.  .  .    706 
Pyopneumothorax         subphrenicus 

496,  590 
Pyrosis 481 


Q- 


Quinsy,  distinguished  from  tonsil- 
litis      446 


R. 


Rachitis    193,  218 

Rales     280, 336 

crepitant,   in   pneumonia 336 

varieties  of 280,  281 

Rash,  mulberry,  of  typhus 808 

Ray    fungus 330 

Raynaud's  disease 666,  722 

mistaken  for  chilblains 723 

for   scleroderma 888 

for  Weir  Mitchell's  disease.  .  .  723 

Recklinghausen's    disease 754 

Records  of  cases,  plans  for 26 

Red  gum  of  infants 891 

Reflex,    abdominal 87 

arc 86 

aural 87 

biceps    88 

binaural   86 

cranial 87 

cremaster 86 

crossed    89 

deep 87 

derangements  of 86 

epigastric 87 

erector    spinse 87 

excitability    97 

gluteal    87 

in  hysteria 196 

jaw    88 

laryngeal  and  pharyngeal. .  .  .   87,  238 

nasal   87 

palatal    87 

palmar    86 

patella  tendon 87 

periosteal   88 

plantar   86 

platysma 87 

reinforcement  of .- .  .  89 

scapular   87 

superficial    86 

tendo   Achillis 88,  216 

toe 88 

triceps 88 

Regurgitation,   aortic 404 

mitral   426 

of  fluid  or  food 484 

tricuspid    423 

Relapsing   fever 819 

bilious   typhoid   form   of 821 


Relapsing       fever       distinguished 
from    typhoid    and    typhus 

fever   822 

from  Weil's   disease 577 

from  yellow  fever 822,  826 

renal  disease  in 821 

spirilla   of 821,822 

Remittent  fever 841 

distinguished  from  acute  conges- 
tion of  the  liver 843 

from  acute  meningitis 844 

from  intermittent  fever 843 

from  typhoid  fever 843 

from  yellow  fever 827 

infantile     846 

sequelse  of 846 

Renal  artery,  embolism  of 762 

multiple  aneurisms  of 707 

calculi     676,  679,  706 

irritation  of 706 

colic    517,  676,  679,  707 

concretions,   forms  of 676 

passage  of.     See  Renal  colic. 

cysts    707 

dropsy    715 

enlargements   602 

growths    simulated    by    ovarian 

tumors    626 

hsematuria   665 

inadequacy     694 

vein,  thrombosis  of 713 

Respiration,  amphoric. .  .    268,    279,  407 

bronchial    274,  279 

broncho-cavernous    280 

cavernous     279 

Cheyne-Stokes     62,  291,  384 

disturbance  of 59 

feeble    275 

harsh 278 

in  children,  peculiarities  of 286 

in  laryngeal  disease 233 

jerking   277 

metallic    280 

metamorphosing  breath-sound. .  .   280 

prolonged 277 

puerile    275 

ratio    334 

rhythm  of 277 

sounds   of.   in   health 274 

supplementary    275 

vesiculo-bronchial   278 

vesiculo-cavernous    280 

Respiratory  movements 260 

Retina,  embolism  of 82 

Retinal    hemorrhage 82 

Retinitis,    albuminuric 83,  690 

diabetic    83,  708 

leuksemic    82 

Retroperitoneal  glands,  cancer  of.    615 

tumors    615 

Retro-uterine    hjematocele 626 

Rheumatic       fever       distinguished 

from    pvtemia 755 

gout    .  .  /. 778 

paralysis 120 


INDEX. 


957 


Eheumatism,  acute 

distinguished  from  acute  syno- 
vitis     

from  cerebro-spinal  fever .  .  . 

from  denguo      

from  milk-leg 

from  rickets 

from  trichiniasis 

head-symptoms  of,  confounded 

with  meningitis 159. 

heart-symptoms    in 

as  a  cause  of  chorea 

associated   with   nodules 

with    torticollis 

cerebral    

chronic   

confounded      witn      neuralgia 
220, 
with  pain  of  organic  struc- 
tural   disease 

with  paralysis  agitans 

in   Bright's  disease 

distinguished  from  gout 

feigned   

gonorrhoeal    408, 

hyperpyrexia  in 

laryngeal    

muscular    772, 

distinguished      from      achillo- 

dynia    

from  Morton's  disease 

from  myalgia 

from    neuralgia 

from  organic  structural  dis- 
ease  

from  sciatica 

from  tetanus 

from  trichiniasis 775, 

■  of  abdominal  walls 

confounded  with  peritonitis 

of  cervical  muscles 

of    lumbar    muscles,    simulating 

abdominal   aneurism 

of   scalp  

periosteal  

subacute     

associated  with  scarlet  fever .  . 
confounded  with  neuralgia .  .  . 

syphilitic   

Ehinitis    229, 

atrophic    231, 

caseosa  and  fibrinosa 

hypera^sthetic    

membranous 

oedomatosa     

Khinoliths    

Rhinorrhoea,  cerebro-spinal 

Hhinoscleroma    

Ehinoseopy 231, 

Hibs,  beading  of,   in  rickets 

caries    of 

Hickets    193,218,438, 

combined  M'ith   scurvy 

confounded    with    craniotabes.  .  . 
with   hereditary  syphilis 


768 

769 
819 
830 
769 
782 
924 

771 
770 
189 

771 

774 
771 

772 

773 

773 
779 
690 
776 
775 
770 
771 
241 
773 

774 
775 
774 
773 

773 
225 
199 
924 
530 
530 
819 


630 
223 
775 
772 
856 
220 
775 
231 
241 
229 
230 
455 
229 
229 
230 
232 
239 
782 
528 
780 
782 
782 
781 


Rickets  confounded  with  mollifies 

ossium  781 

with   rheumatism 782 

diagnosis    of 781 

Ringworm  of  the  scalp 890 

Risus  sardonicus 198 

Romberg  symptom 139 

Rontgen  light 262 

See  also  X-rays. 

Rose-cold    230,  307 

Roseola   874 

Rotheln    861 

Rubella     861 

associated  with  pyelitis 704 

distinguished   from   measles....  861 

from  scarlet  rever 862 

from  typhus  fever 863 

Rubeola  sine  catarrho 859 

Rumination    484 

Rupia   882 

S. 

Salaam   convulsions 193 

Salivation    443 

Salpingitis     537 

vSand  in  intestines   509 

Saprsemia     758 

Sarcinse    ventriculi 480,  506 

Sarcoma,  mediastinal ........    361,  434 

of  hypogastric  region 627 

of  kidney 692 

of  larynx 257 

of  lymphatic  glands 750 

of  nose 232 

Sarcomata  of  brain 214 

Sausage    poisoning 896,  925 

Scabies   879,  889 

Scalp,  loss  of  sensibility  in 57 

oedema  of,  in  cerebral  thrombosis  173 
rheumatism  of,  confounded  with 

hemicrania    223 

Scarlatina    853 

anginose 855 

associated  with  rheumatism ....    856 
complications  and  sequelae  of...    856 
distinguished    from    cerebro-spi- 
nal  meningitis 818 

from    dengue 830,  858 

from    erysipelas 869 

from  laryngeal  diphtheria  454,  857 

from    measles 857 

from    rubella 862 

from   smallpox 857 

from  typhoid  fever 857 

followed  by  dropsy 856 

by    epilepsy 856 

leucocytosis  in 855 

nervous  symptoms  in 855 

pseudo-  857 

rash   of 854 

sine   exanthemate 854 

sore   throat   of 854 

surgical    857 

tongue  in 855 


958 


INDEX. 


Scarlet  fever.     See  Scarlatina. 

Sciatica    224 

distinguished  from  hip- joint  af- 
fections     225 

from  irritation  of  the  Icidney.   225 

from  rheumatism 225 

feigned    , 225 

of  diabetic  source 708 

Scleroderma  or  sclerema 819,  886 

Sclerosis,  cerebro-spinal 145,  217 

chronic,  of  posterior  and  lateral 

columns    141 

disseminated    141 

distinguished  from   chorea 191 

lateral,  amyotrophic 116,  117 

multiple 145 

posterior 116,  138 

pseudo-disseminated 146 

spinal    116 

Scrofula 31,  538,  876 

associated  with  disease  of  intes- 
tines        555 

pulmonary   330 

Scrofulous     glands     distinguished 

from  lymphadenoma 750 

Scurvy , 554, 764 

combined  with  rickets 782 

confounded  with  purpura 766 

infantile     764 

sore  mouth  of 443 

Seborrhoea    ,    878,  891 

Secretion,   deranged 151 

Senile  dementia 217 

Sensation,    deranged 64 

gnawing,  in  vertebrae 441 

Sensations  of  patients 48 

tests  of. ...  , 67 

Sensibility,    electrical ,.      65 

perverted    70 

Sensory   centres   of   brain 55 

impressions    56 

nerves   64 

Septicaemia    757 

from  absorption  of  toxines 758 

malarial    758 

puerperal   757,  759 

typhoid     758 

Septum  of  nose,  deviation  of 229 

Shock    33 

Shoulder,    stiffness    of,    in    chronic 

pleurisy    358 

Sinus,  frontal,  diseases  of 228 

Skiagraph 262 

Skiameter 263 

Skin,  actinomycosis  of 890 

condition  of,  as  a  symptom 31 

during  typhoid  fever 790 

discoloration    of,    following    fe- 
vers    '.  .  .    753 

from  lactation  and  pregnancy  753 

hereditary    753 

in  Addison's  disease 752 

diseases    871 

bullous     879 

constitutional    873 


Skin  diseases,  erythematous 873 

from  altered  gland-secretion.  .   891 

from   iodism 881 

nervous     892 

papular    875 

parasitic    888 

pustular 880 

squamous     882 

syphilitic   882,  883,  892 

table    of 872 

vesicular    877 

dryness  of 152 

hypertrophies   of 886 

maculae  of 884 

new    growths    of , 884 

pigmentation    of 709,751,884 

trophic  changes   in 65 

Skoda's    sound 350 

Sleep,      protracted,      distinguished 

from   apoplexy 175 

Sleeping  sickness 184 

Smallpox    864 

confluent    865,  870 

distinguished  from  erysipelas.    870 

from    measles 859 

from  scarlet  fever 857 

from  varioloid 867 

eruption  of . 864 

invasion   of 864 

malignant 866 

sequelae  of 866 

Sneezing,  as  symptom  of  gout.  ...   778 

Snoring 231 

Softening  of  the  brain,  acute. .    158,  175 

ehronic 207 

discriminated  from  abscess .  .  .    209 

from   atrophy 209 

from  cerebral  anaemia.  .....    208 

from  congestion 208 

from    exhaustion    of    brain- 
power       205 

from  neurasthenia 206 

from  tumor 210 

paralysis   from. 208 

relations  of,  to  hemorrhage. .  .    207 

Somnolence    62, 219 

Sopor 62 

Sore  throat 445 

chronic 456 

rheumatic    .  , 457 

clergyman's     457 

follicular    457 

syphilitic   457 

Sound,  adventitious 280 

amphoric    .' .  .  .    268 

bronchial    274,  279 

cracked-pot  or  cracked-metal. .  .  .    268 

elicited  by  percussion 266,  355 

Hippocratic,  or  succussion 266 

oesophageal     461 

sibilant  and  sonorous 280 

splashing  and  gurgling,  in  stom- 
ach        506 

tracheal,  Wintrich's 434 

tympanitic 267 


INDEX. 


959 


Spasm,   carpopedal 200 

facial,  distinguished  from  chorea  192 
masticatory,  of  the  face,  distin- 
guished from  tetanus 199 

of  arterioles 722 

of  bladder  confounded  with  colic  517 

of  glottis 244 

Spasmodic  dorsal  tabes 116 

Spasms    149 

See  also  Convulsions. 

centric  and  eccentric 150 

clonic  and  tonic 149 

diseases  marked  by 184 

facial 192 

functional 202 

mobile 192 

of  acute  cerebral  disease 191 

rhythmic,  of  the  head 150 

saltatory 150 

tetanic,  symptomatic 199 

Spastic  spinal  paralysis 116 

Speech,   defective 131,  141 

Spermatorrhoea  206 

Sphincters,  loss  of  control  of 115 

Sphj'gmochronograph    38 

Sphyginogram    36 

of  aortic  insufficiency 425 

of  contracted  kidney 698 

of  gouty  heart 411 

of  mitral  regurgitation 425 

of  thoracic  aneurism 435 

Sphygmographs    34,  35,  411 

Spinal  cord,  anaemia  of 113 

congestion  of 112 

diseases   of 50 

gout  of 777 

hemorrhage  into 107 

inflammation  of .  .  . 113 

distinguished  from  epidemic 

cerebro-spinal  meningitis.  817 

lesions  of 56 

morbid    conditions    of,     as    a 

cause  of  paraplegia 107 

nutritional  disease  of 206 

sclerosis  of 116 

syphilis  of 123 

table  of  diseases  of 153 

tumors  of 117 

Spinal  curvature 219 

in  chronic  pleurisy 358 

hemorrhage    107 

irritation    , 113 

localization    56 

meningitis    108,  113 

myelitis 114 

sclerosis    116 

disseminated    145 

lateral 116 

amyotrophic 117 

Spine,  concussion  of 115 

deviation    of 132 

in  chronic  pleurisy 358 

disease  of,  confounded  with  an- 
eurism      630 

with   colic 519 


Spine,   irritable    113 

Spirometer   265 

Splanchnoptosis    463,  507 

Spleen,  aflections  of 617 

displacement   of 624 

embolism  in  artery  of 762 

enlargement    of 362,618,795 

chronic     618 

distinguished   from    cancer    of 

kidney    618 

from  chronic  pleurisy 362 

from  fecal   accumulations..    618 

hereditary    618 

in  typhoid   fever 795 

gastric  hemorrhage  in 483 

infarct    in 399 

inflammation    of 617 

lesion  of,  in  relapsing  fever....   821 

percussion    of 466 

size    of 467 

Spotted   fever 812 

Sputum    294 

albuminous    363 

constituents    of 295 

crystals   in 296,  308 

elastic  fibres  in 296 

fibrinous  coagula  in 296 

nummular    313 

pai'asites    in 297 

resembling    currant- jelly 324 

prune-juice    324,  334 

rusty     334 

spirals    in 296,  308 

Squamous    diseases 882 

Starvation   of  heart 415 

Station   29,  94,  139 

Status   epilepticus 185 

Stenosis,    bronchial 258 

laryngeal    256 

of    bowel 470 

of  pylorus 504 

Stereognosis    70 

Stethogoniometer   265 

Stethometer   264 

Stethoscope    271 

Stitch  in  the  side 350 

Stokes's  sign 520 

Stomach,  acidity  of,  excessive  476,  499 

activity  of,  absorptive 475,  504 

acute  diseases  of 489 

cancer  of 497, 599 

contrasted  with  cancer  of  liver  599 

with   chronic  gastritis 501 

with  cirrhosis  of  liver 609 

with  gastric  ulcer 501 

catarrh    of 491 

chronic  aflfections  of 491 

cramp  of 484 

dilatation    of 480,  505 

confounded  with  dilatation  of 

large   intestine 507 

connected  with  tetany...    200,506 

diseases    of 470 

dislocation  of 506,  507 

electricity    to 471 


960 


INDEX. 


Stomach,   examination   of 470 

of  contents  of .  .  .   471,  492,  499,  506 

fibroid  thickening  of 504 

gout    in 777 

liemorrhage    from 482,  495,  894 

hour-glass  constriction  of 508 

inflammation  of 489 

inspection  of  interior  of 471 

insufflation  of 469 

lithsemic  pain  in 778 

motility   of 500 

motor   activity   of 475 

neuralgia   of 487 

organic    disease    of,    confounded 

with  pernicious  anaemia 743 

pain  in,  as  a  symptom.  .  .  .   484,  489 

percussion    of 467,  469 

perforation    of 525 

distinguished     from     irritant 

poisoning    894 

peristaltic  disturbance  of 515 

physical  examination  of,  instru- 
ments   for 571 

rupture    of 149 

softening    of 491 

tests  in  diseases  of  471,492,499,506 

ulcer   of 493,505 

perforating 496 

Stomatitis,    aphthous 444,910 

gangrenous    444, 452 

mercurial     443 

ulcerative,  confounded  with  diph- 
theria      452 

Stools  as  symptoms 509 

bilious    509 

black 510 

dry  and  watery 509 

examinations    of 510 

fat    in 560 

shape    of 510 

Strabismus     79,  177,561 

Streptococcus    399, 451 

erysipelatis    869 

pyogenes     342,  755 

Streptocytus   of   Schottelius 910 

Stricture  from  nasal  polypi 232 

of  the  oesophagus 459 

Stridor,  laryngeal 245 

Strongylus  gigas 918 

Strychnine    poisoning 901 

confounded  with  tetanus.    201,901 

Stupor    62 

in  ursemia 686 

St.  Vitus's  dance.     See  Chorea. 

Suffocation    307 

Sugar  in  the  urine 655,  707 

tests    for 655,710 

Sugar  of  millc 658 

Sulphates  in  urine,  pathology  of.  .    649 
Sun-bronzing  confounded  with  Ad- 
dison's  disease 753 

Sun-stroke   180 

distinguished  from  apoplexy....  180 
Suprarenal  capsules,  disease  of...  754 
Swaying 29,  94,  139 


Sweat-glands 891 

Sweating,  acid 769,  790 

bloody 152,891 

excessive 152,  908 

fatal    801 

Sycosis   882,  889 

Symptoms,  pathognomonic 21 

Syncope    •.  .      63 

distinguished  from  apoplexy. .  .  .    175 

from    epilepsy 187 

Synovitis,   acute,   confounded  with 

acute  rheumatism 769 

Syphilis,   congenital 123 

constitutional    883 

distinguished  from  Addison's  dis- 
ease         753 

from    rhinoscleroma 232 

hereditary    123 

of  spinal  cord. 123 

Syphilitic  disease  of  bowels 548 

of  brain 214,711,840 

of    kidney 692 

of    liver 593,  608 

of    lungs 324 

distinguished  from  phthisis  324 

of    mouth 444 

of   oesophagus 460 

of  skin.    753,  877,  879,  882,  883,  892 

of   spinal   cord 123 

of  throat    457 

fever  confounded  with  intermit- 
tent  fever 839 

paralysis    122 

rheumatism   775 

stenosis    460 

teeth   123,  781 

ulcers  of   fauces 457 

Syphiloderm    877 

Syphiloma  of  brain  causing  poly- 
uria   711 

Syringomyelia  131,  152 


T. 


Tabes   dorsalis 138,  142 

See  Locomotor  ataxia. 

mesenterica    622 

pseudo- 476,  622 

spasmodic    dorsal 116,  147 

tremor   in 147 

Tachycardia    32,  387 

Tactile  sense,  impairment  of 68 

Taenia   echinococci 916 

lata    916 

mediocanellata    915, 916 

solium     914,  915,  916 

Tape-worms 914,  916 

of    pork 914,916 

Teeth,  loss  of 140 

Hutchinson's  or  notched...    123,781 

Temperature  as  a  symptom 38 

cerebral    40 

extraordinary    44,  45 

in  apoplexy 168 


INDEX. 


961 


Temperature  in   appendicitis 535 

in  cancerous  affections 45 

in  catarrhal  fever 786 

in  cerebro-spinal  fever 814 

in  children 43 

in   cholera 565 

in    dengue 829 

in  gastric  ulcer 495 

in    hepatic    fever 579 

in  intermittent  fever 837 

in  Malta  fever 832 

in  measles 858 

in  pernicious  anaemia 741 

in  pernicious  fever 847 

in  phthisis 315 

in    plague 831 

in  pneumonia 44,  334 

in  puerperal  peritonitis 524 

in   pyaemia 755 

in  relapsing  fever 820,  822 

in  remittent  fever 841 

in  rheumatism 44,  771 

in    scarlatina 44,  854 

in   smallpox 864,  866 

in  spinal  injury 44 

in  tetanus 44,  198 

in  triehiniasis 923 

in  typhoid  fever 44,  790 

in  typhus  fever 808 

in  yellow   fever 44,  823,  825 

of  abdomen 40 

of  head 40 

of  surface 38 

epigastric     495 

subnormal    45 

variations 58 

Temperature  sensibility 69,  145 

altered 68 

tests  for 69 

Tenderness  as  a  symptom 49 

epigastric     491 

Tendo-Achillis  jerk 88 

Tenesmus     545, 549 

Tetanus    108,  191,  197 

confounded  with  hydrophobia.  .  .    201 

with  local  rigidity 199 

with  spasms  in  scarlet  fever.  .    199 
with  strychnine  poisoning  201,  901 
distinguished  from  cerebro-spinal 

fever   199,  817 

from  chorea 191 

from  masticatory  spasm 199 

from  meningitis 199 

from  muscular  rheumatism. .  .    199 

from  tetany 200 

hysterical   198 

idiopathic 197 

traumatic   197 

Tetany    193,  200,  506 

associated   with   laryngismus.  .  .    244 

Chorstek's  symptom  in 200 

distinguished     from     carpopedal 

spasm   200 

Trousseau's   symptom  in 200 

Thermal  impressions,  paths  of ...  .      56 


Thermal    sense 69,  145 

Thermometer,  clinical  use  of 40 

See  also  Temperature. 

Thermometry,  cerebral 40 

general   40 

surface   38 

Thirst   as   a   symptom 476 

Thomsen's   disease 203 

Thoracic    aneurism 432 

confounded  with   abscess  of  the 

mediastinum   434 

with  chronic  laryngitis 439 

with   dilated   auricle 437 

with  insufficient  aortic  valves  436  . 
with       intrathoracic      morbid 

growth    433 

with  malformation  of  the  chest  438 
with  malposition  of  the  aorta  438 

with  pulsating  empyema 436 

with   pulsation   of   pulmonary 

artery 437 

eructations    in 478 

Throat,   follicular   disease  of 457 

inflammation  of 456 

soreness  of,  chronic 456 

in  scarlet  fever 457,  854 

rheumatic    457 

ulcers  of,  syphilitic 457 

Thrombosis 759 

cerebral     169,  172 

from    chlorosis 760 

from  enfeebled  nutrition 179 

from   exhausting   diseases 760 

of  brain  sinuses 211,  759 

of  cerebral  arteries 172 

of  mesenteric  vessels 760 

of  renal  vein 713 

Thrombus,   changes   in 764 

Thrush   443 

Thymus  gland 219 

Thyroid    gland 219,389,438 

extirpation  of 744 

swelling    of 389 

Tic  douloureux 64,  222 

Tinea    888,  889 

circinata    888, 890 

decalvans     890 

favosa   889 

sycosis    889 

tonsurans     888, 890 

versicolor     884,  890 

Tinnitus   aurium 86 

Tongue,  cancer  of 445 

coating  and  color  of 47 

condition  of,  in  disease 45,  444 

dryness  or  humidity  of 46,47 

inflammation    of 445 

in  intermittent  fever 838 

movements  of 46 

one-sided  furring  of '.  .    152 

slips  of 178 

syphilis    of 445 

Tonsil,    abscess    of 248 

'  cancer    of 446,  458 

chancre    of 458 


60 


962 


INDEX. 


Tonsil,    enlargement   of 446 

herpes  of 452 

pharyngeal  231 

Tonsillitis     241,  248,  446 

acute    follicular 447,  451 

associated  with  rheumatism.  .  .  .    768 
confounded  with  diphtheria....   451 

Torpor    157 

Torticollis    774 

Toxines,  absorption  of 758 

Trachea,  affections  of 233,  257 

foreign  body  in 248 

inflammation  of 243 

morbid  growths  in 257 

narrowing  of 258 

symptoms  of  diseases  of 234 

ulcers    in 257 

Tracheal  tugging 435 

Trance 183 

distinguished  from  narcolepsy..    176 

Tremor   144 

alcoholic 147 

arsenical 147 

asthenic    148 

convulsive 191 

essential  148 

fimctional    147 

hereditary    148 

hysterical 148 

in  exophthalmic  goitre 148,  390 

in  spasmodic  tabes 147 

intention 144 

lead     147, 906 

mercurial     147, 905 

post-hemiplegic 147 

senile 147 

tobacco   147 

Trial    meal 472,  499 

Trichina  spiralis 919,  921 

Trichiniasis     775,  919,  921 

distinguished  from  Bright's  dis- 
ease        925 

from   cardiac   disease 925 

from  cholera  morbus 925 

from  irritant  poisoning 925 

from  periarteritis  nodosa ....    925 

from    rheumatism 775,  924 

from  sausage  poisoning 925 

from  typhoid  fever 923 

from   typhus    fever 923 

fever   of 922 

muscular    symptoms   of 923 

oedema    in 923,  925 

pulmonary  symptoms  in 924 

Trichocephalus    dispar 914 

Trismus    198,  817 

Trophoneuroses 151 

Trousseau  sign 244 

Tube  casts.     See  Urine,  casts  in. 

Tubercle   bacilli 297,299,885 

tests    for 297 

calcareous  transformation  of .  .  .   330 

in  brain 160,  214 

in  intestines 333,  554 

of   choroid 83 


Tubercular    diarrhoea 554 

meningitis   160,  817 

peritonitis   539 

pleurisy    323,  363 

Tuberculosis  of  kidney 692 

of    lungs 313,332 

acute     304,  331 

See  also  Phthisis. 

acute  miliary 332,  805 

combined  with  laryngitis 255 

with  pyloric  obstruction .  .  .   504 

with  typhoid  fever 805 

with  typhus  fever 810 

Tuberculous     aspiration     broncho- 
pneumonia         342 

Tujnors,  abdominal 519,  617 

in    hypochondria 617 

aneurismal    290, 310 

cerebral 210 

distinguished  from  abscess.  ...   211 
from  chronic  meningitis.  .  .  .    211 

from  softening 210 

from  thrombosis  of  sinuses.   211 

nature  of 214 

seat  of 212 

syphilitic    214 

unilateral  symptoms  of 213 

epigastric     619 

fatty    627 

gliomatous 214 

hydatid,   of   kidney 707 

in  cortex  of  brain 212 

in  epigastrium 619 

in  hypogastric  region 626 

in  iliac  and  lumbar  regions  624,  625 
in  left  and  right  hypochondrium  617 

in  umbilical  region 622 

intracranial  210 

intrathoracic,    confounded    with 

chronic   pleurisy 360 

mediastinal    361,  433 

non-aneurismal,  confounded  with 

abdominal   aneurism 630 

with  thoracic  aneurism ....   435 

of   cerebellum 212 

of  epigastrium 619 

of  larynx 256 

of    liver 600 

of  pons  or  crus .  .  . .   212 

of  spinal  cord 117 

of   spleen 618 

ovarian     625 

phantom     621 

pulsating    630 

retroperitoneal    615 

umbilical    622 

Tympanites    536,  615 

chronic,     confounded     with     as- 
cites        615, 616 

of  soldiers 616 

Typhlitis    535 

Typhoid      conditions      confounded 

with  typhoid  fever 802 

Typhoid   fever 789 

abortive    577,  805,  806 


INDEX. 


963 


Typhoid    fever,    absence    of    intes- 
tinal  lesions   in 806 

affections    resembling 521,522 

appendicitis    in 800 

bacillus   of 793,  801 

blood  in 798 

bloody  stools  in 793 

cerebral    819 

coexisting  with  malaria 806 

complications  of 799 

confounded  with   acute   atrophy 

of    liver 583 

with    appendicitis 536,  803 

with  cerebro-spinal  fever 816 

with  enteritis 803 

with  general  debility 802 

with  meningitis 162,  804 

with  peritonitis 803 

with  pulmonary  affections  334,  804 

with    pyaemia 755 

with  relapsing  fever 822 

with  scarlet  fever. 857 

with   trichiniasis 923 

with  typhoid  conditions 802 

with  typhus  fever 810 

with     ulcerative     endocarditis 

399,  804 

con\'Tilsions    in 796 

delirium  in 795 

diarrhoea    in 792 

diazo-reaction   in 792 

discoloration  of  hands  and  feet 

in     798 

distinguished  from  Malta  fever.    832 

from  remittent  fever 843 

from  yellow  fever 826 

enlargement  of  the  spleen  in .  .  .    795 

epistaxis  in 797 

eruption    in 797 

febrile  symptoms  of 790 

mania   in 795 

mild   form  of 805 

nervous  symptoms  in 795 

pain  a  symptom  in 795 

palsy    in 796 

perforation    in 800 

pulse  in 790 

relapses    in 798,806 

renal  type  of 792 

septicsemic   758 

sequelae    of 799,  801 

spinal   symptoms   in 796 

temperature    in 790 

walking    802 

Widal  test  in 794 

Typhoid    septicaemia 758 

Typho-malarial    fever 852 

Typhus    fever 807 

acute  tuberculosis  in 810 

bacillus  of 807 

cerebral    symptoms    in 808 

cerebro-spinal    812 

coma-vigil    of 808 

compared  with  typhoid  fever.  .  .    810 
complications    in 810 


Typhias     fever     confounded     with 

measles 859 

with  yellow  fever 827 

distinguished  from  acute  menin- 
gitis      809 

from  cerebro-spinal  fever 819 

from   plague 831 

from  relapsing  fever 822 

from  rubella 863 

from    trichiniasis 923 

eruption  in 808 

maculated  or  spotted 808 

pulse  in 809 

temperature    in 808 

Tyrosine     583, 652 


U. 


Ulcer,  gastric 493,  505 

confounded  with   chronic  gas- 
tritis        492,  501 

with  gastric  cancer.  .  .  .   497,  501 
with  ulcer  of  duodenum ....   497 

followed  by  cancer 505 

perforating    496 

laryngeal    256 

of   bowel,   albuminuric 555 

follicular  and  solitary 555 

syphilitic   548 

of    duodenum 497 

of   ileum 536 

of    mouth 444 

of  typhoid,  unhealed 555 

of  ureter 677 

peptic    497 

perforating,   of   foot.  .  .    140,  152,  912 

of    stomach 496 

stercoral     552 

tubercular,  of  bowel 555 

of  mouth 444 

typhoid     800 

Umbilical  region,  pain  and  tender- 
ness in 520 

tumors    of 622 

Uraemia    686,  897 

convulsions  in 687 

delirium  in 60,  687 

distinguished    from    cerebro-spi- 
nal  fever 819 

mania  in,  acute 687 

Uraemic    coma    distinguished   from 

apoplexy    174. 686 

from  narcotic  poisoning  680,  897 

in  Bright's  disease 686 

Urates  as  calculi 676 

pathology    of 644 

tests    for 645 

Urea,   pathology  of 638 

tests    for 639 

instruments  for 640 

Ureometer    640 

Ureter,    inflammation    and    ulcera- 
tion of 677 

Urethra,  hemorrhage  from 668 


964 


INDEX. 


Uiethral     fever     confounded    with 

intermittent  fever 839 

Uric  acid   641 

calculi    644, 676 

detection    of 642 

in    gout 776 

in   litlisemia 644 

murexide  test  for 641 

quantitative  estimation  of .  .  .    642 
Urinary  organs,  diseases  of..    632,675 

Urine    632 

abnormal  substances  in 650 

acetone  in 658,  709 

acidity    of 637 

albumin   and   other    proteids   in 

659,  662 

principal  tests  for 659 

albuminose   in 661 

albuminous  condition  of,  diseases 

marked    by 680,  698 

alcaptone   in.  .  .• 652,  657 

alkalinity  of 638,  646,  701 

analysis    of 632 

bile  in 653 

biliary  acids  in 654 

blood    in 663,  849 

guaiacum  test  for 663 

blood-extractives  in 659 

calcium  oxalate  in  492,  650,  666,  676 

casts  in,  blood 682 

mucous  696 

tube  - 682,  698,  792,  821 

chlorides   in 336,  505,  648 

tests    for 648 

chylous   670 

color  of,  changes  in 635 

constituents  of,  changes  in  quan- 
tity  of 638 

cystine    in 676 

decreased  discharge  of 712 

diacetic  acid  in 658 

diazo-reaction   of 792 

estimate  of  solids  in 636 

fat  in 670 

fibrin  in 671 

globulin    in 662 

glycuronic  acid  in 658 

hsematoporphyrin  in 635 

haemoglobin  in 570,  663,  666 

in  acute  yellow  atrophy 583 

in  alcohol  poisoning 898 

in  apoplexy 168,  174 

in  Bright's  disease 681,  688 

in  carbolic  acid  poisoning 899 

in  chlorosis 739 

in    cirrhosis 605 

incontinence  of 615,  712 

increased  discharge  of 707 

in    diabetes 707,710,712 

in   Duhring's   disease 881 

indican  in 533,  549,  654 

in  gastric  disease 500,  505 

ingredients   of 634 

in    haemoglobinuria 666 

in  hemorrhagic  malarial  fever .  .    849 


Urine  in  jaundice 569,  653 

inosite  in 658 

in  phosphorus  poisoning 895 

in  pneumonia 335 

in   relapsing  fever 820,  821 

in  remittent  fever 843 

in   typhoid   fever 792 

in  typhus  fever 810 

in  Weil's  disease 576 

in  yellow   fever 827 

kreatin  and  kreatinin  in 650 

kyestein   pellicle   on 670 

lactic  acid  in 782 

leucine    in 583,  639,  652 

leucocytes   in 669 

melanin  in 635 

mucin  or  nucleo-albumin  in  659,  663 

normal    632,  634,  659 

of  the  insane 711 

oxalate  of  lime  in 492,  650,  676 

oxybutyric   acid   in 658 

peptones  in 659,  662 

phosphates  in 492,  645,  676 

alkaline  and  earthy 645,  647 

mixed    676 

phosphoric  acid   in 648 

pigment    in 635 

purulent,  confounded  with  acute 

Bright's  disease 683 

diseases   associated  with 700 

pus    in 668,700,704 

quantitative  examination  of ...  .   638 

reaction    of 637 

retention    of 713 

sediments  in 633,  671 

specific  gravity  of 636 

specimens,  manner  of  obtaining  633 

sugar  in 293,  655,  708,  710,  898 

sulphates   in 649 

suppression    of 707,  712 

table    showing    action    of    tests 

uj^on    671 

toxicity    of 674 

tyrosine    in 584,  639,  652 

urates    in 644,  676,  843 

urea  in 638,  810,  843 

uric  acid   in 641,  676 

urobilin  in 635 

xanthine   in 676 

Urinometer    636 

Urobilin    606,  635,  739 

Urochrome 635 

Uroerythrin     635 

Urticaria    875 

Uterus,  colic  of 518 

gravid,   confounded  with  ascites  615 

hemorrhage  from,  in  myxcedema  718 

Uvula,   enlarged   245 


V. 


Vagrant's    disease 753 

Valve,  aortic,  disease  of 424,  427 

insufficiency  of 436 


INDEX. 


965 


Valve,   mitral,   disease   of....   424,426 

pulmonary   artery 428 

tricuspid,  affections  of 423,  427 

Valvular    affections    of    the    heart 

417,  426 
confounded  with  functional  car- 
diac   disorder 419 

with  malformations  of  heart.   418 
with  misdirection  of  current.  .   419 
diagnosis  of,  before  development 

of   murmur 431 

from  rupture  of  a  valvulet  or  of 

a  papillary  muscle 430 

table   of 426 

Varicella    867 

followed  by  gangrene 868 

Variola.     See  Smallpox 864 

Varioloid   867 

Veins,  diseases  of, 721 

enlargement    of...    382,441,605,720 

portal,  inflammation  of 608 

thrombosis  of 609,  759 

associated  with  cancer 760 

in   exhausting   and   wasting 

diseases    760 

renal,  thrombosis  of 713 

thrombi    in ., 759 

Vena  cava,  occlusion  of 441 

Venous  hum 294 

pulsation 38 

Ventricles,  hemorrhage  from 170 

Vertigo  73 

aural   74,  85 

cerebral 73,210 

essential   76 

from  overwork  of  brain 76 

laryngeal    76, 245 

lithsemic 74 

of  malassimilation 74 

paroxysmal  or  paralyzing 75 

precursor  of  epilepsy 76 

stomachal 74 

syphilitic    122 

Vessels,   amyloid  degeneration  of.    506 
mesenteric,  thrombosis  ot 760 

Vibrio  proteus.  . 562 

Viscera,  abdominal  percussion  and 
auscultation    of 465,  470 

Vision,  derangement  of .  .  .  .    76,  83,  778 

double 79 

lithsemic  disorder  of 778 

Vocal  cord,  cysts  of 257 

diseases   of 253,  254 

fremitus     284 

paralysis  of 290 

resonance    284,  285_ 

spasm  of  tensors  of 251 

Voice,  altered 233,  250 

amphoric    284 

auscultation  of 284 

cavernous   284 

changes  in,  in  laryngeal  diseases  233 

loss  of 253 

metallic    284 

strain  of 250,  251 


Voice    without    vocal    cords 254 

Vomit,    black 482,  824,  827 

coffee-ground     483, 499 

different  forms  of 479 

sarcinse  and  fungi  in 480 

Vomiting  as  a  symptom 59,  478 

bilious    481 

cerebral    59,  496 

diseases  accompanied  by  478,  489,  561 

fecal    481,  541 

gastric    479,  496 

mucus     481 

nervous     479 

of    bile 481,562 

of    blood 482,495,583 

in  irritant  poisoning 894 

of  food  or  liquid 480 

of    pus 481 

watery    481 


W, 

Water-brash    481 

Water,   contamination   of,   causing 

infectious   jaundice 576 

causing    a     fever     resembling 

typhoid 803 

Weak  back 774 

Weil's    disease 576 

Whitlows,  painless 132 

Whooping-cough     248,292,312 

distinguished   from   acute   bron- 
chitis       293 

from    bronchial    phthisis 293 

Widal  test  in  continued  fevers.  .  .  .    785 

in  pneumo-typhus 805 

in  typhoid   fever 794,  844 

in  typho-malarial  fever 853 

in  typhus  fever 810 

Windpipe,  foreign  bodies  in 248 

Wool-sorters'    disease.  .  .• 909 

Word-blindness    53,  179 

Word-deafness  53,  179 

Worms,  intestinal 118,  738,  913 

round    913 

seat-  and  thread- 913 

tape- 914 

Wrist   clonus 89 

drop 110 

Writer's  cramp 192 

Wry-neck  774 


X. 

Xanthelasma   600,  872 

Xanthine    670 

Xerostomia    47 

X-rays    202 

in  examination  of  aneurisms...  441 

of  joints 779 

of  kidneys 680 

of  larynx 238 

of  lungs  and  heart 262 

of    stomach 508 


966 


INDEX. 


Yeast    fungi 480 

Yellow  atrophy  of  liver 582 

Yellow  fever 823 

attended,     with     bronzing     of 

skin  753,824 

confounded    with    atrophy    of 

liver    583 

with  bilious  remittent  fever  827 

with   dengue 830 


Yellow  fever  confounded  with  hem- 
orrhagic   malarial     fever  850 

with    plague 826 

with  relapsing  fever . . .   822,  826 

with  typhoid  fever 826 

with  typhus  fever 827 

walking    825 

Z. 

Zinc  poisoning 895,  908 


THE    END. 


<s>. 


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